register@nursesoncall.co.

za
Telephone: 086 1000 930
Fax: 086 455 7118

REGISTRATION FORM
Please ensure certified copies of all supporting documentslisted below are submitted with a completed
registration form:
Copy of ID Proof of Hepatitis Injection
Copy of SANC Receipt Nursing Certificates
Proof of Professional Indemnity BLS Certificate
Matric Certificate Copy of bank statement
Please note incomplete applications will NOT be accepted

1. PERSONAL INFORMATION

FULL NAME AND SURNAME ________________________________________________ I.D. NO___________________________

RESIDENTIAL ADDRESS ________________________________________________________________CODE ________________

POSTAL ADDRESS ______________________________________________________________________CODE ________________

TELEPHONE NO. HOME ___________________ WORK _____________________ CELL: ________________________

EMAIL ADDRESS ____________________________________________________________________________________

CONTACT PERSON AND TELEPHONE NUMBER IN CASE OF EMERGENCY: ________________________________________

GENDER: MALE_____________ FEMALE_____________

INCOME TAX REFERENCE NUMBER: ___________________________________________________

2. CRIMINAL RECORD

Do you have any CRIMINAL RECORDS YES____________ NO____________

If YES then provide DETAILS

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

3. PROFESSIONAL INFORMATION

SANC REFERENCE NUMBER: __________________________ RECEIPT NUMBER: ________________________________

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 RN ENENACG

ARE YOU: TRAINEDEXPERIENCED

DO YOU HAVE YOUR OWN TRANSPORT? YES  

ARE YOU REGISTERED WITH ANY OTHER AGENCY? YES  

IF YES, PLEASE STATE THE NAME OF THE AGENCIES ……………………………………………….

Have you had a hepatitis injection? ………………………………If NO, you are required to have a hepatitis injection

If YES, please provide the date and Proof of Injection: ………………………………….

4. EMPLOYMENT HISTORY

Please start with most current employer / Practical Experience

NAME OF EMPLOYER (Hospital) POSITION (Self) WARDS WORKED / Duration of Employment

HAVE YOU WORKED IN A PRIVATE HOSPITAL: YES NO

NAME OF HOSPITAL _______________________________________________________ DATE: _______________________________

PLEASE SPECIFY BELOW WARDS THAT YOU CAN WORK IN ORDER OF PREFERENCE, AS PER YOUR QUALIFICATION OR
EXPERIENCE.

1. _________________ 2. ___________________ 3. ____________________ 4. __________________

5. REFERENCES

INSTITUTION CONTACT PERSON & POSITION TELEPHONE NUMBER

6. PLACEMENT AFTER REGISTRATION

1. _________________ 2. ___________________ 3. ____________________ 4. __________________

7. BANKING DETAILS:

NAME OF ACCOUNT HOLDER _________________________________________________________________________________

BANK _______________________________________ BRANCH NAME _________________________ACC TYPE: _____________

BRANCH CODE ____________________________ ACCOUNT NO _____________________________________________

Please Note: Any changes to banking details needs to be communicated to Nurses on Call in Writing

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 Herein after Agreement of Terms and Conditions of Employment between Nurses on Call cc (NOC) and

____________________________ (Assignee).

8. PREAMBLE

The Assignee accepts and understands that Nurses on Call is not directly able to secure permanent employment and further understands that the
assignmentshas arisen purely as a result of temporary business requirements of Nurses on Call’s Client Medical Institutions. This is based on
hourly shifts, not exceeding 12 hours at a time. Nurses on Call will however always try its utmost to secure temporary employment, as often as
possible when the need arises, however there is no guarantee for continuous assignments. Hours of work will be determined by the availability of
assignments and this may vary between client hospitals.

9. TERMS AND CONDITIONS

9.1 DEDUCTIONS
Payments are done on a weekly basis.

Nurses on Call complies with the directives as set out by SARS. Tax deductions will be done as per Tax Tables which are updated by SARS
annually if Nurses on Call is your only employer. If Nurses on Call is your Secondary employer and full time employment is held elsewhere 25%
tax Deduction will apply.

DECLARATION OF INCOME: Please indicate below if Nurses on Call is:

Primary Employer (Temporary Employment with NOC) - Taxed as per Tax Tables __________________

Secondary Employer (Permanently Employed) - Taxed @ 25% __________________

I undertake to notify Nurses on Call, in writing of any changes in my employment status immediately.

It is also compulsory for Nurses on Call to Comply with the requirements of the Unemployment Insurance Fund. This will ensure you to claim
unemployment benefits in future and is determined by a deduction of 2% of gross earnings, 1% payable by the Employer and 1% by the
Employee.

Annual leave is paid weekly based on an “All Inclusive” rate as set out by the Minister of Labour through Ministerial Determination. A copy of
the Ministerial Determination is available to the Assigneeat each Nurses on Call branch. Nurses on Call does however offer assignees the option
of annual leave being paid on a weekly basis or to deduct 5.88% of each payment to accrue for annual leave. Please indicate with a tick if Nurses
on Call should:

Payout Leave Weekly ______________

Deduct 5.88% of weekly Payments ______________

Nurses on Call reserves the right to deduct monies from the Assignee’s remuneration, ONLY in the event of an overpayment or incorrect
payment.

Garnishing Orders will be deducted should a court order be served on Nurses on Call.

9.2 POLICIES AND PROCEDURES

The Assignee accepts the responsibility to become accustomed to the Policies and Procedures of both Nurses on Call and the Client Hospitals
which he/she will be assigned to.

The Assignee needs to provide Nurses on Call with a valid and up to date copy of Professional Indemnity Cover.

This agreement specifically indemnifies and hold harmless Nurses on Call and the Clients of Nurses on Call against any claims arising from
Unemployment, Injury on Duty, Illnesses, Death or any form of damages, whilst the Assignee whilst contractually employed by Nurses on Call.

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 Nurses on Call therefore insists that the Assignee, has provided for the necessary Cover in relation to the afore mentioned and is made available to
Nurses on Call upon request.
The Assignee is required to have all their Hepatitis B immunization up to date and be fit for duty.

The Assignee is aware that there is a 4-hour cancellation policy if the Assignee in unable to arrive on duty and work for a confirmed shift. Failure
to cancel the scheduled shift within this timeframe will result into a 6-hour penalty fee at the hourly earning rate of assignee. Nurses on Call can
cancel the shifts of the Assignee if the Client no longer require their services.

The Assignee is aware of the uniform Policy of the Agency, and adheres to this, and is also aware that he /she should not wear any other uniform
whilst representing Nurses on Call. If this is not adhered to a penalty will apply.

The Assignee acknowledges English as the Communication Language whilst representing Nurses on Call with their Client Hospitals.
The Assignee is aware that they should arrive on duty 15 minutes prior to the commencement of his/her confirmed shift.

The Assignee should wear all the necessary Personal and protective equipment, which are in line with the Health and Safety regulations.

The Assignee should familiarize themselves with the legislative requirements for an Injury on Duty (IOD). The Assignee is aware that it is their
responsibility to inform Nurses on Call of an injury within 24 hours/ as soon as possible. The Assignee is also aware that if Personal and
Protective Equipment and procedures were not followed and the injury was due to negligence, then he/she will be liable for injury cost.

9.3 DISIPLINARY PROCEDURES

The Assignee hereby agrees that he/she will make themselves available to Nurses on Call to investigate any matter/complaint arising from the
Client Hospitals where the Assignee may be subjected to within 5 working days. Outcomes of any matter/complaint will be communicated to
client hospitals.

The assignee acknowledges the use of cellular telephones are not allowed whilst on duty. Using a cellular phone whilst on duty will result in
disciplinary Proceedings.

The Assignee acknowledges their awareness that he/she is not allowed to work for the agency for two consecutive shifts within a 24-hour period.
If this is breacheddisciplinary Proceedings will be followed

The Assignee is aware that sleeping on duty is a dismissible offence.

9.4 GUARANTEE OF COMPETENCE

The Assignee guarantees that he/she has the necessary qualifications and experience to completely carry outthe services which he/she has
undertaken under this contract.

The Assignee further declares that there is no medical condition, either of a physical or psychological nature, of which he/she is aware that would
impede his/her performance on the job or which could hold an actual or potential risk to the health and safety of the employee himself/herself, a
fellow employee or a member of the public.

The Assignee shall ensure always that he/she is registered with the South African Nursing Council and Renewals of this Registration is updated
and provided to Nurses on Call annually.

The Assignee also agrees to participate in the compulsory Continuous Professional Development (CPD) under the guidance of a Clinical Trained
Specialist.

The Assignee acknowledges no employment can commence without Hospital Induction and Orientation, which will be done by a Nurses on Call
Facilitator.

The Assignee and Employer can terminate this contract in writing based various legitimate reasons between one to 30 working days.

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DECLARATION

I hereby declare that all particulars and answers in this application are true and no material has been withheld. I agree that my withholding of any
material information or failure to answer the questions correctly will constitute a breach of a condition of my employment for which I could face
disciplinary action of dismissal.

I consent Nurses on Call to check all the details provided to various sources for authenticity. I further consent Nurses on Call to forward and retain
any personal information provided within this application to various clients with my prior consent.

I, _________________________________________________ (full name & surname)

Identity number _________________________________________.

Signed at _________________________________ on this _________day of ________________ 201___

_________________________ _______________________________
Employee Signature Witness Signature