Quality Living Care Registration Online Form

Title*

First Name*

Middle Name

Last Name*

Maiden or Previous Name (If Applicable)

Date of Birth

Email*

Password*

Enter password again*

Address Line 1*

City*

Post Code

Country*

Home Phone Number

Work Phone Number

Mobile Number*

Fax Number

Skype ID

Preferred Method Of Contact*

NMC Pin Number

NMC Pin Expiry Date

Tick Membership

RCNMDU

Membership Number

Membership Expiry Date

Qualification Achieved

Adult General Nursing: Grade

Adult General Nursing: Date Taken

Children's Nursing: Grade

Children's Nursing: Date Taken

Learning Disability Nursing: Grade

Learning Disability Nursing: Date Taken

Mental Health Nursing: Grade

Mental Health Nursing: Date Taken

Midwifery: Grade

Midwifery: Date Taken

Attach Transcript Obtained

Attach Your CV

NMC Test*

NMC Test Date Taken

Attach NMC Test Results

All applicants must meet English language requirements, with an International English Language Test (IELTS) score of 7.0.

Any English Language Test (IELTS) taken more than 2 years ago will be in valid and candidates will have to retake this exam.

English Language Test Result: Grade

English Language Test Date Taken

Country of Origin*

Choose one of the fields that is applicable to you*

Currently in UK and Will not need sponsor LicenceCurrently in UK and Will need sponsor licenceCurrently outside UK and will need sponsor licenceUser Input

Current / Most recent employer:*

Your Job Title*

Your Job Role

Employer Address*

Your Start Date*

The Date You are Leaving (If Applicable)

Your Salary per annum/hour

Please give the names and addresses of 2 professional referees (at least one of whom we can contact immediately for a reference).

Both referees must have known you in a professional capacity for a minimum of 6 months and one should be your most recent employer.

Primary Referee:

Please note this referee will be contacted immediately.

Organisation Name*

This is my*

Organisation Address*

Contact Name*

Email*

Telephone*

Job Title / Position within the company*

Length of time known*

Organisation Name*

This is my

Organisation Address*

Contact Name*

Email*

Telephone*

Job Title / Position within the company*

Length of time known*

Please indicate if you are happy for us to also contact this employer immediately*

Title*

First Name*

Last Name*

Relationship*

Daytime Telephone

Evening Telephone

Mobile Number*

Address*

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