1. Name

2. County No. of Detachment

3. How long have you been acquainted with her?

4. Have you attended her professionally?

5. For what complaint?

6. Is she intelligent and of active habits?

7. General health?

8. Has she flat feet, hammer-toe, or any other defect?

9. Is her vision good in each eye?

10. Is her hearing perfect?

11. Has she sound teeth, and if not, have they been properly attended to by a Dentist lately?

12. Has she shown any tendency to Rheumatism, Anaemia, Tuberculosis, or other illness?

13. When?

14. What?

15. Has she ever had influenza?

16. Does she suffer from headaches?

17. Any form of fits?

18. Heart disease or varicose veins?

19. Is she subject to any functional disturbance?

I have on the ................................. day of 191.... seen and examined ....................................... and hereby certify that she is apparently in good health, that she is not labouring under any deformity, and is, in my opinion, both physically and mentally competent to undertake duty in a Military Hospital, and is
^[*]A. Fit for General Service.
B. Fit for Home Service only.
C. Unfit.

Date (Signed) Address

[*] Kindly delete categories which do not apply.

Reference No.: J.W. 19c.

JOINT WOMEN'S V.A.D. DEPARTMENT. Territorial Forces Association. British Red Cross Society. Order of St. John of Jerusalem. DEVONSHIRE HOUSE, PICCADILLY, LONDON. W1.

QUALIFICATIONS of Members of Women's Voluntary Aid Detachments for Nursing Service or General Service.

1. (a) Name in full (Mrs. or Miss). (b) If Married state Maiden Name.

2. Permanent Postal Address. Present Postal Address.

3. Telephone No.

4. Telegraphic Address.

5. Detachment County and No. B.R.C.S.
St. John Brigade.
St. John Association.

6. Name and Address of Commandant of Detachment.

7. Rank in Detachment.

8. Time of Service in Detachment.

9. Age and Date of Birth.

10. Place and Country of Birth.

11. Nationality at Birth.

12. Present Nationality.

13. Height.

14. Weight.

15. Where Educated.

16. At what age did you leave school?

17. Whether Single, Married, or Widow.

18. If not Single, state Nationality of Husband.

19. Name and Address of Next-of-Kin or Nearest Relation residing in the British Isles.

20. Father's Nationality at Birth.

21. Mother's Nationality at Birth.

22. Father's Profession.

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:--

Date .......... Signed .................... Commandant.

Date .......... Countersigned .................... County Director.

NOTE.--Commandants are held responsible for all statements on this form being accurate so far as it is possible for them to find out, also for the fact that the member who signs it is a British subject, and in every way suitable for appointment by the Joint V.A.D. Committee.

This form must be signed by the Commandant, who should then send it to the County Director for counter signature and forwarding to Headquarters.

Application No.

For Official use only.

CONFIDENTIAL.