LOCUM OCCUPATIONAL HEALTH NURSING PRACTITIONERS - APPLICATION AND
PERMISSION FORM
PERSONAL CONTACT DETAILS:
Surname:_________________________________
Full names:_________________________________
Identity
number:
_______________________________________________________________
Residential Address:
___________________________________________________________
_____________________________________________________________________________
Contact Telephone Number:
(___)_______________________________
Cell: _____________________
E-mail address:
______________________________________
SANC registration number:
______________
SASOHN
membership number: ___________
QUALIFICATIONS:
(please circle either Yes or No)
Registered Nurse: Y/N
Enrolled Nurse: Y/N
Nurse Assistant: Y/N
Primary Health: Y/N
Audiometry:
Y/N
Occupational Health: Y/N
Dispensing Course:
Y/N
HOW MANY YEARS EXPERIENCE DO YOU HAVE IN OCCUPATIONAL HEALTH?
________
NAMES AND CONTACT DETAILS OF 2 REFERENCES AT COMPANIES WHERE YOU
PREVIOUSLY PERFORMED LOCUM WORK:
Name: __________________
Company: ________________
Tel no: ___________________
Name: __________________
Company: ________________
Tel no: ___________________
AVAILABILITY:
Which demographical area are you available to work in?
_______________________________
DISCLAIMER (Please complete and sign):
I, ______________________________,
ID number ___________________ hereby give SASOHN permission to provide
my personal details to any party with regards to locum work.
I agree that I will update my details as needed and will
not hold SASOHN responsible for outdated information provided to
a prospective employer.
I understand that SASOHN will merely provide my name and details
as provided on this form to enquiring parties.
Any agreement entered into will be between me and the employer
and SASOHN will have no interest in the agreement.
Signature:
_____________________________
Date: ___________________________
Should any of your details change, please notify:
SASOHN National Office:
Email:
sasohnoffice@mweb.co.za
Tel: (011)
892 3174
Fax: (011) 892-5355
|
