Skip to content

info@leadcarerecruitment.com

Facebook Instagram Linkedin

Fast Track Apply

Menu

Home
About
Doctors
Nurses
HCAs
Clients
- Hire Health Staff
Training Academy
Join Leadcare
News
Contact

info@leadcarerecruitment.com

Home
About
Doctors
Nurses
HCAs
Clients
- Hire Health Staff
Training Academy
Join Leadcare
News
Contact

APPLY AS A NURSE

APPLICATION FORM

Applying to Leadcare Recruitment couldn’t be easier; simply complete the online application form below and one of our friendly recruitment consultants will get in touch to guide you through the process.

Staff Nurse Application Form

"*" indicates required fields

Step 1 of 12

8%

Please allow yourself sufficient time to complete the application accurately.

To assist you, we have created the following checklist of information you will need to have available before starting your application:

Minimum experience: At least 6 months’ nursing experience within the NHS / HSC / HSE
Driving licence: Full UK driving licence with access to a car (mandatory for some roles)
NMC PIN number
Education details
Employment history: Must date back to the age of 18, any gaps need fully explained
References: Two references from managerial staff at Band 6 / Band 7 or above, with at least one from your current or most recent employer

Important: Please note that the application form must be completed and submitted in one sitting. Ensure you have all required information ready before beginning to avoid any interruptions.

Thank you for your attention to detail. We look forward to receiving your completed application.

Before you begin your application, could you let us know how you heard about us? Please select one of the options below*

A Friend or Family Member

Google

Social Media (Facebook, Instagram, LinkedIn)

Job Boards (Indeed/JobsNI)

Leadcare Website

Other

If you selected "Other", please explain

CAPTCHA

Personal Details

Title*

Mr

Mrs

Miss

Ms

Other

Name*

First Last

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date Of Birth*

Mobile No.*

Email*

Do you hold a full UK driving licence?*

Yes

No

Do you have access to your own vehicle?*

Yes

No

Professional Details

National Insurance No.*

Nursing Experience*

(Years & Months)

NMC PIN Number*

Next Of Kin Details

Name*

Relationship*

Contact No.*

Eligibility to Work

Are you eligible to work in the UK?*

(You will be required to provide a copy of an eligible passport or visa)

Yes

No

Have you ever been involved in disciplinary/dismissal proceedings with an employer?*

Yes

No

If you answered Yes to the above, please explain*

Are you currently under investigation by NMC/NISCC?*

Yes

No

If you answered Yes to the above, please explain*

Have you ever been subject to investigations in the past?*

Yes

No

If you answered Yes to the above, please explain*

Have you ever been subject to safeguarding investigation?*

Yes

No

If you answered Yes to the above, please explain*

Do you have any cautions with NMC/NISCC?*

Yes

No

If you answered Yes to the above, please explain*

Which one of the following Nursing qualifications are applicable to you?*

Adult

Mental Health

Midwife

Pediatric

Learning Disability

Other

If you answered Other to the above, please explain*

Which specialist areas would you prefer to work in?*

Medical

Surgical

Oncology

A&E

ICU/HDU

Theatre/Recovery

Paediatrics

Mental Health/Learning Disability

Other

If you answered Other to the above, please explain*

Which HSC trust would you prefer to work in? e.g. Western, Northern etc.*

*Please note, You cannot work as an Agency Nurse within a trust you are currently employed in.

Northern Trust

Western Trust

Southern Trust

Southeastern Trust

Belfast Trust

Do you currently work for another nursing agency?*

Yes

No

If you answered Yes to the above, please state which one/s*

Would you have any interest working in Care Homes?*

Yes

No

Education (University)

Please provide the following details for your most relevant qualification (Degree).

List*

Add a new row for each Course.

Date From (Day/Month/Year)

Date To (Day/Month/Year)

Course Take

Grade Obtained

Education Continued ( A level/GCSE/Alternative )

Subjects & Grades*

Add a new row for each Subject & Grade.

Level

Subject

Grade/Result

Employment History

Please provide a complete record of your previous employment, starting with your Current or Most Recent Employer.
It is a mandatory requirement by the RQIA that your employment history must date back to when you turned 18 years old. Incomplete employment history will result in your application being returned.
If there are any gaps in your employment history, please provide an explanation in the section below.
Note if you need to add additional tabs click on add more

Employment History (1)

Date From*

Day/Month/Year

Date To*

Day/Month/Year

Date From*

Date To*

Employer Name*

Clinical Area/Department/Ward*

Position/Grade*

Main Duties/Responsibility*

Reason For Leaving*

Employment History (2)

Date From*

Day/Month/Year

Date To*

Day/Month/Year

Date From*

Date To*

Employer Name*

Clinical Area/Department/Ward*

Position/Grade*

Main Duties/Responsibility*

Reason For Leaving*

Employment History (3)

Date From*

Day/Month/Year

Date To*

Day/Month/Year

Date From*

Date To*

Employer Name*

Clinical Area/Department/Ward*

Position/Grade*

Main Duties/Responsibility*

Reason For Leaving*

More Employment History

Add More Employment History

Employment History (4)

Date From*

Day/Month/Year

Date To*

Day/Month/Year

Date From*

Date To*

Employer Name*

Clinical Area/Department/Ward

Position/Grade*

Main Duties/Responsibility*

Reason For Leaving*

More Employment History

Add More Employment History

Employment History (5)

Date From*

Day/Month/Year

Date To*

Day/Month/Year

Date From*

Date To*

Employer Name*

Clinical Area/Department/Ward

Position/Grade*

Main Duties/Responsibility*

Reason For Leaving*

More Employment History

Add More Employment History

Additional Employment History

Additional Employment History

(Including Dates, Employer Name, Position, Reason For Leaving)

Gaps in Employment

If there are ANY gaps in your employment history, please provide an explanation below. Be sure to include:

Date Period: Clearly indicate the time frame of the gap (e.g., DD/MM/YYYY to DD/MM/YYYY).
Reason for the Gap: Provide a brief explanation (e.g., pursuing education, personal circumstances, traveling, family commitments, etc.).

List

Date From (Day/Month/Year)

Date To (Day/Month/Year)

Reason for Gap

Comments

Working Time Directive

Under the Working Time Regulations (Northern Ireland) 2016, employees are not required to work more than an average of 48 hours per week, calculated over a 17-week reference period, unless they choose to opt out of this limit.

By signing this agreement, you confirm that you voluntarily agree to disapply the 48-hour weekly limit and may work more than 48 hours per week if required.

You understand that:

Signing this agreement is entirely voluntary, and you will not be treated unfavourably if you choose not to sign.
You may withdraw your consent at any time by providing one week’s written notice to Leadcare Recruitment.
This agreement remains in effect until withdrawn in writing.

Employee Declaration*

I understand that if I choose to revoke this agreement in the future, I must provide Leadcare Recruitment with a minimum of 4 weeks' written notice

I hereby agree to opt out of the 48-Hour Agreement as specified in the Working Time Directive.

Signature*

Your Name
Your Name
Your Name

Rehabilitation of Offenders Act 1974

The provisions of Section 4.2 of the Rehabilitation of Offenders Act 1974 do not apply to any employment that relates to the provision of health services and which enables the post holder to have access to persons in receipt of such services in the course of their normal duties. Therefore, applicants must declare any criminal convictions, including those which would otherwise be considered ‘spent’.

Do you have any convictions or cautions?*

Yes

No

If you answered Yes to the above, please explain the details*

Are you currently the subject of any criminal proceedings?*

Yes

No

If you answered Yes to the above, please explain the details*

Are you currently the subject of any police investigation?*

Yes

No

If you answered Yes to the above, please explain the details*

Are you aware of any reason you cannot work with children or vulnerable adults?*

Yes

No

If you have answered ‘yes’ to the above, please explain*

Access NI Enhanced Disclosure

All applicants will be asked to apply for an Access NI Enhanced Disclosure as part of the recruitment process. “Code of practice” can be found on the NI direct website. Failure to do so will result in an unsuccessful application. Any change in criminal conviction, proceedings, or investigations status post-employment must be communicated to Leadcare Recruitment as a matter of urgency.

Disability Discrimination Act 1995

Having read the description below, do you consider yourself to have a disability?*

The act defines disability as a physical or mental impairment which has a substantial and long-term effect on a person's ability to carry out normal day-to-day activities. (If you take medication, treatment or have a prosthesis to manage your condition, would you consider that you had a disability if you were without these? If so, you should answer `yes' below.)

Yes

No

If you have answered ‘yes’ to the above, you can explain about that below

References

Please provide the details of two references, ensuring one is from your Current or Most Recent employer at a senior level than yourself (e.g., Band 6/7/8).
Important Notes:

If you have worked for an agency, provide the agency's contact details.
References from Band 5 nurses will no longer be accepted. Submitting an unsuitable reference will result in your application being returned.

Reference 1

Can we contact this reference before your interview?*

Yes

No

Name & Address*

Clinical Area/Department/Ward*

Position*

Email*

Phone*

Reference 2

Can we contact this reference before your interview?*

Yes

No

Name & Address*

Clinical Area/Department/Ward*

Position*

Email*

Phone*

GDPR - General Data Protection Regulation

Please view our website for the full privacy policy. The link to the website is: https://leadcarerecruitment.com/privacy-policy/

I confirm that I have reviewed the privacy policy and I would like to subscribe to Leadcare Recruitment's mailing list, including receiving communications via email, phone calls, texts, shift availability updates, payment information, and compliance notifications.

I confirm that I have read this document thoroughly and that all the information provided to Leadcare Recruitment is accurate to the best of my knowledge. I understand that knowingly giving false information will disqualify me from registration with Leadcare Recruitment. I understand that knowingly giving false information will disqualify me from registration with Leadcare Recruitment

I give consent for Leadcare Recruitment to share my personal information, including my personal data and file, with third parties for audit purposes. Additionally, I give consent to contact referees regarding the information I have provided unless specified otherwise. I will inform Leadcare Recruitment of any changes that might affect my position, and I understand that the information given in this form will be processed by computer and used for registration purposes under the Data Protection Act 1998.

Confirm you have read and understand the information below regarding GDPR*

Please view our website for the full privacy policy. The link to the website is: https://leadcarerecruitment.com/privacy-policy/

I confirm that I have reviewed the privacy policy and I would like to subscribe to Leadcare Recruitment's mailing list, including receiving communications via email, phone calls, texts, shift availability updates, payment information, and compliance notifications.

I confirm that I have read this document thoroughly and that all the information provided to Leadcare Recruitment is accurate to the best of my knowledge. I understand that knowingly giving false information will disqualify me from registration with Leadcare Recruitment. I understand that knowingly giving false information will disqualify me from registration with Leadcare Recruitment

I give consent for Leadcare Recruitment to share my personal information, including my personal data and file, with third parties for audit purposes. Additionally, I give consent to contact referees regarding the information I have provided unless specified otherwise. I will inform Leadcare Recruitment of any changes that might affect my position, and I understand that the information given in this form will be processed by computer and used for registration purposes under the Data Protection Act 1998.

I confirm I have read and understand the above.

Declaration

The information I have given in this application form is, to the best of my knowledge, complete, factual, and accurate in all aspects. I understand that knowingly giving false information will disqualify me from registration with Leadcare Recruitment. As an Employment Agency, we collect and store data about you to enable us to process your application and register you with the Agency. This may include sensitive data.

I hereby freely give Leadcare Recruitment consent to process and store my personal data relating to my application and registration with the Agency.

By signing this declaration, I acknowledge that I meet the following requirements of Leadcare Recruitment:

A minimum of 6 months Nursing experience within the NHS/HSC/HSE
Adhere to professional development policy in completion of annual appraisals and if required a minimum of 2 Clinical Supervision sessions.
I understand that if I am charged or cautioned at any stage after signing this declaration, I must inform Leadcare Recruitment.
I am not aware of any condition, medical or otherwise, that would affect or limit my employment or performance, other than those declared in my Occupational Health Form.
I acknowledge and confirm that Leadcare Recruitment is authorized to apply for and obtain a Disclosure and Barring Service (DBS) check and references from any previous employers and educational establishments.
I declare that the information given herein is true and complete and is not presented in a way intended to mislead. I agree that if I have given false or misleading information or omit relevant information now or in the future, Leadcare Recruitment may cease to offer me further agency placements without notice, as well as claim for recovery of any payments I have received, together with a claim for loss of profit to Leadcare Recruitment.
I acknowledge that my personal details will be stored and handled correctly by Leadcare Recruitment in accordance with the Data Protection Act 1998. However, I agree that they may be made available for audit/review by relevant third parties. (This is relevant for all information, including all documents - DBS, Occupational Health, References, Right to Work).
I understand that if I am on a Tier 2 Sponsorship Visa, I can only work for a maximum of 20 hours per week at the same professional level as my sponsorship. I understand that I have a responsibility to monitor this. Additionally, if my position with my sponsored company changes, I must inform Leadcare Recruitment.
I acknowledge that if any of my details stated on this Application Form change, or my circumstances change, which may affect my ability to work for Leadcare Recruitment, I must inform Leadcare Recruitment immediately.
I confirm that I am not currently under investigation, or currently suspended, by my professional regulatory body or being investigated by my current or previous employer. I will inform Leadcare Recruitment if I am under investigation or suspended by my professional regulatory body or employer at any point while working for Leadcare Recruitment.

Date*

Signature*

Your Name
Your Name
Your Name

Derry/Londonderry HQ:
Leadcare Recruitment
North West Business Complex
Derry/Londonderry
BT48 8SE

Belfast HQ:
Leadcare Recruitment
The Kelvin
17-25 College Square E
Belfast
BT1 6DH

Quick Links

Fast Track Application
Browse Jobs
Contact Us
External Training Payments

Resources

Access NI Code Of Practice
Leadcare Complaints Procedure
Disclosure Information Handling
Equal Opportunities Form
Recruitment of Ex-Offenders
Reference Request Policy
Leadcare Training Terms & Conditions

Copyright © 2026 Leadcare Recruitment : Powered by NI Web Solutions