Part 19

23. Religion.

24. (a) If you volunteer for nursing duties state what experience you have had in wards.

(b) Name and address of hospital.

(c) Date.

25. Certificates held.

26. (a) Nursing. (f) Motor Driver. (b) Kitchen. (g) Laboratory Attendant. (c) Clerical. (h) X-Ray Attendant. (d) Storekeeping. (i) House Work. (e) Dispenser. (j) Pantry Work.

27. State what experience and qualifications you have had for Categories in No. 26.

28. Have you been inoculated against Enteric Fever? If so, what date? If not, are you willing to be?

Have you been vaccinated? It so, what date? If not, are you willing to be?

29. Your usual Occupation or Profession? Your present Occupation or Profession?

30. Give the Names and Addresses of two British Householders with permanent addresses in the British Isles who have known applicant for two or more years, but are not related to applicant, to act as References, having previously obtained their permission to use their names.

(a) (Mayor, Magistrate, Justice of the Peace, Minister of Religion, Barrister, Physician, Solicitor or Notary Public). Acquaintance dating from year _______ (b) Lady. Acquaintance dating from year ______

31. Name and Address of Head of College or School, recent Business Employer, Head of Government Department, Secretary of Society or some other person who can be referred to for a report on your qualifications for the work selected. (The Quartermaster of your V.A.D. could be given if you have worked in her department.)

In what capacity employed?

How long employed? Year?

32. Are you willing to serve at home or abroad?

33. Are you willing to serve in Civil Hospitals from which personnel have been withdrawn for War Service?

34. Are you willing to serve:--

(a) With pay, (b) For expenses only, on the terms of service laid down in our terms of service?

N. B.--Members who can afford to work for their expenses only are urgently needed.

35. Date after which you will be available for duty.

36. (a) Are you pledged to serve in any other organisation? (b) If so, what?

37. (a) Have you served with the Women's Legion or any similar organisation? (b) If so, what?

I hereby declare that the above statements are complete and correct to the best of my knowledge and belief.

Date .......... Usual Signature ..........

For Office Purposes, please add your full Christian Names and Surname legibly written.

I certify that the above declaration is, to the best of my knowledge and belief, true; and that M ............ is a fit and proper person to be employed by the Joint V.A.D. Committee.

REMARKS:--