Personal Details

We are open 24 hours a day, Please specify times at which you are not to be contacted below.

Career History

Please confirm your career history details for the last 5 years. Please list using most recent first.

Career History

Please confirm your career history details for the last 5 years. Please list using most recent first.

Qualifications & Training

You should supply any certificates such as ENB or Diplomas etc -please note that we require manual handling/CPR certifications that have been updated in the last 12 months.

Recordable Qualifications

Midwives Only

Medical History

Have you ever suffered from any of the following:

Have you ever been vaccinated, immunized or tested for/against any of the Following?


Glory Crown requires 2 professional references. It is essential that you have had professional dealings with both of your references within the last 2 years.

OPT Out Agreement


In this Agreement the following definitions apply:-
“Assignment” means the period during which the Temporary Worker is engaged in services to a Client.
“Client” means the person, firm or corporate body that has engaged the services of the Temporary Worker.
“Employment Business” means Glory Crown.
“Temporary Worker” means a Qualified Nurse, care assistant or other Temporary Worker.
“Working Week” means an average of 48 hours each week as calculated over any 17 week period.


The Working Time Regulations of 1998 state that a Temporary Worker shall not work on an Assignment with a client in excess of the Working Week unless they agree in writing that this limit should not apply.
The Temporary worker, by signing the declaration below, agrees that the Working Week shall not apply to their Assignments.
The Temporary Worker can end this Agreement at anytime by giving the Employment Business 14 days notice in writing. After the 14 day notice period has expired the Working Week shall apply immediately.
It should be noted, that any notice ending this Agreement does not mean that a Temporary Worker has ended an Assignment with a Client.
These laws are governed by English Law and are subject to the jurisdiction of the English Courts.


I have read and fully understand the above OPT OUT AGREEMENT.
I hereby consent that the Working Week limit shall not apply to my Assignments.
I understand that I can end this Agreement by giving the Employment Business 14 days notice in writing.

Next of Kin Details


Rehabilitation of Offenders Act

Due to the nature of the work for which you are applying, this post is exempt from the provisions of section 4.2 of the rehabilitations of offender’s act 1974 (exemption order 1975). Applicants are therefore, not entitled to withhold information about convictions which for other purposes are ‘spent’ under the provisions of the act and in the event of employment. Failure to disclose such convictions could result in dismissal or disciplinary action.

Any information given will be completely confidential and will be considered only in elation to an application for positions in which the order applies, and should be entered at the end of any particulars you give in support of your application.

A copy of our written policies is available upon request. A criminal record will not necessary be a bar to obtaining a position.

With an enhanced disclosure, under section 4.2 of the rehabilitation of offenders act 1974 (exemption order), all previous cautions, warnings and convictions will always be detailed regardless of how long ago.

Any conviction, caution, reprimand will require a written statement of each and every event and how it does not affect your suitability for the role you are applying for.



I confirm that the information I have provided in support of this application is complete and true and understand that knowingly to make a false statement could be a criminal offence.

I consent to Glory Crwonchecking the details I have provided against the various data sources in order to verify my identity and process the application. These details may be recorded and used to assist other organisations for identity verification purposes such as the CRB, regulatory bodies such as NMC or GSCC.

Glory Crown retains the right to hold this application and any other data required to process this application (whether in the UK, European Union or elsewhere) and keep for as long as necessary in line with the data protection act.

Additional Information/Checklist

On receipt of a satisfactorily completed application form, Glory Crown will provide/send the following:-
1. Assist you with your DBS application for an enhanced DBS. The charge for this will be £44.00 (cheques to be made payable to Glory Crown Ltd).

Please tick boxes:

Full Immunisation record:

Training Certificates including:

We will also need details of your Bank / Building Society account for our Payroll Department.

We try to make our registration process as swift and painless as possible but we are sure that you understand that owing to the sensitive nature of your profession that our checks have to be thorough.