35 Woodford Avenue, Gants Hill, Ig2 6Uf

CANDIDATE APPLICATION FORM

VERSION 1.0

35 WOODFORD AVENUE, GANTS HILL, IG2 6UF

TEL: 0207 096 5087 / 0208 5031966, EMAIL: , WEBSITE: www.rsmtopjobs.com

1.  PERSONAL INFORMATION

Title (Dr, Mr, Mrs, Ms, Miss)
Date of Birth (DD/MM/YYYY)
Gender / MALE FEMALE
Forename
Surname
Other Names
Marital Status
National Insurance Number
(Please provide proof of NI)
Home Telephone
Mobile
Email
Skype
Full Drivers Licence (Yes or No) / YES NO
Current Address
Post Code

2.  NATIONAILTY

British/EU National (Yes or No) / YES NO
Nationality
Passport Number
Expiry Date
Visa Type
Visa Number
Expiry Date

3.  NEXT OF KIN

Name
Relationship
Current Address
Post Code
Home Telephone
Mobile
Work

4.  PROFESSIONAL REGISTRATION

Membership Body / GMC NMC HCPC OTHER
Membership Number
Year Registered (YYYY)
Grade/Band/Level
Speciality
Licence to Practice / YES NO
Specialist Register / YES NO
Are you currently being investigated by GMC, NMC or HCPC? (Yes or No) / YES NO
If Yes, please give details
Who has been your main employer for the last 12 months?
Do you currently have a Responsible Officer (GMC) / Confirmer (NMC) / Responsible Officer (GMC) Confirmer (NMC)
Name of Officer/Confirmer?
Officer GMC number/Confirmer NMC Pin
Revalidation Date? DD/MM/YYYY

* It is the responsibility of the applicant to inform “The Agency” of any changes to their registration

5.  APPRAISAL MANAGMENT

I confirm that I am aware of the GMC’s and NMC’s performance monitoring processes and that I have made formal arrangements to be appraised regularly by an appropriate trained medical healthcare professional.
YES / NO
Name of Appraiser
Contact Details
Date of Last Appraisal
Date of Next Appraisal
Additional Information

6.  EDUCATION AND TRAINING

University/Institution/Training
Qualification
Date of Graduation
TRAINING / YES / NO / DATE COMPLETED
Life Support (BLS, ILS and ALS)
Mandatory Training
Safeguarding Children
Safeguarding Adults
Practical Manual Handling (within the last 3 years)

7.  PROFESSIONAL REFERENCES

* Please provide contact details for two Consultants (Doctors) or Seniors (Nurses) whom you have worked with in a clinical setting on your two most recent positions

Referee Name
Position
Location/Company/Trust
Telephone/Mobile
Email
Referee Name
Position
Location/Company/Trust
Telephone/Mobile
Email

* I understand and agree to “The Agency” applying and disclosing copies of my references for the purposes of finding me assignments

Signed
Print Name

8.  INDEMNITY INSURANCE

Name of Insurer
Starting Year of Policy (YYYY)
Policy Number
Level of Cover

I do not hold indemnity insurance. I understand that I may not be fully covered under some NHS trusts insurances and “The Agency”. All Private engagements will need the candidate to have their own personal indemnity insurance.

Signed
Print Name

9.  BANK DETAILS

Do you work via?

Pay As You Earn – PAYE (PLEASE COMPLETE P46 FORM)

Umbrella PAYE Company (THIS MUST BE A UK BASED COMPANY)

Limited Company (YOU MUST BE A MINIMUM 51% SHAREHOLDER)

Umbrella Limited Company (THIS MUST BE A UK BASED COMPANY)

Self Employed – The Agency will ask you to complete a self employed declaration form and you cannot work self employed if you are under Supervision, Direction and Control of the end client.

Bank Name
Bank Address
(UK BASED ONLY)
Post Code
Name on Account
Account Number (8 Digits)
Sort Code (6 Digits)

* Please provide proof of your bank account i.e. bank statement (must contain bank details and address)

Complete if applicable: Limited Company

Name of Limited Company
Registration Number
Unique Tax Reference Number
VAT Number
Name of Accountant
Contact Details
Address of Accountant Company
Post Code

Complete if applicable: Umbrella Company

Name of Umbrella Company
Contact Details
Address of Umbrella Company
Post Code

* Please attach copy of your certificate of incorporation and a copy of your VAT Certificate

10.  EQUAL OPPORTUNITIES

Specify if you wish:

“The Agency” is an Equal Opportunity Employer. We therefore ensure all recruitment decisions are based solely on the basis of merit and suitability for the assignment. In order to monitor the effectiveness of our policy, we ask all applicants to provide the information requested below.

Sex: MALE FEMALE

Age Group: 16-35 36-49 50-64 65+

Disability:

The Disability Discrimination Act 1995 describes a disabled person as someone who “has a physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day to day activities”. It remains your responsibility to report health conditions or impairment to the appropriate manager, if this is likely to impact your ability to carry out your duties. In many cases adjustments can be made by “The Agency” to allow people to continue in the same role.

I consider myself to have a disability: Yes No Prefer not to say

Please specify (if you wish)

Ethnic Group:

Please ensure you read all the categories listed below and tick the appropriate box that best describes your ethnic origin. As this could be origin of you antecedents, it is not necessarily the same as your nationality.

White Black-Caribbean Black-African Black-Other

Indian Pakistani Chinese Mixed

Other ......

Faith:

If you feel your faith is not represented please detail in “other”

None Christian Jewish Buddhist

Muslim Sikh Hindi Prefer not to say

Other ......

Sexual Orientation:

If you feel your sexual orientation is not represented please detail in “other”

Hetrosexual Lesbian Gay Bisexual

Transgender Prefer not to say Other ......

* By completing this form, I agree that “The Agency “may hold this information; it will only be used for Equal Opportunities monitoring purposes and does not form a part of my application process. If at any point I wish for the information to be removed from your record, I can request this.

11.  PERMISSION TO VIEW FILE DECLARATION

To Whom It May Concern,

I hereby give you full permission to request and obtain full copies of all my occupational health reports and history including all vaccinations and serology reports from Trusts/Surgeries/Associates who may hold records. I give full permission for “The Agency” to request any training certificates that their associates or third parties may hold. I am aware my file may undergo and audit due to the contracts “The Agency” holds. “The Agency” may scan electronically my documentation for the purpose of verifying ID.

Signed
Print Name
Date

12.  DECLARATION OF CRIMINAL RECORD & REHABILITATION OF OFFENDERS ACT 1974*

As a healthcare worker you must complete an enhanced DBS check. Due to the nature of the work for which you are applying the provision of Section 4 of the Rehabilitation of Offenders Act 1974 does not apply. The amendments to Exceptions Order 1975 (2013) provide that certain spent convictions and cautions are “protected” and are not subject to disclosure to employers, and cannot be taken into account. Do you have any convictions, cautions or reprimands or final warnings that are not “protected” as defined by the rehabilitation of Offenders Act 1974 (Exception) Order 1975 (as amended in 2013). Any information you may give will, of course, remain strictly confidential. I give permission to “The Agency” to disclose any required information to third parties and associates.

Have you ever been Police checked? (I.e. DBS, PVG etc.) Yes No

Are you on the DBS update service? Yes No

Have you ever been convicted of a criminal offence? Yes No

If “YES” please give details below

Details of Convictions or Cautions
Offence
Date of Convictions or Cautions
Sentence

13.  INTERNATIONAL WORKERS

Have you worked and/or lived outside the UK within the last 3 months? Yes No

In the last 6 months have you spent 12 weeks outside the U.K Yes No

* If “YES” please provide an overseas police check dated within 3 months.

I.E.L.T.S (International English Language Testing System)

I can confirm I have passed each of the four academic modules of the IELTS test as administered by the British Council.

If “YES” please provide a copy of the full certificates

Signed
Print Name

14.  WORKING TIME REGULATIONS

The Working Times regulations 1998 “the Regulations” require “The Agency” to limit your average weekly working time to 48 hour, unless you agree with us that this limit should not apply to you. “The Agency” proposes to have an agreement with you, which will apply until terminated by notice, on the basis that:

A) The 48 hour weekly average working time limit will not apply to you

B)  You may terminate this agreement so that the 48 hour working time limit would apply, by giving the Person at “The Agency” to whom you usually report, 4 weeks written notice

Under the Regulations, “The Agency” must keep records relating to your working time. This is the case whether or not you reach an agreement with us about waiving working time limits.

If you accept our proposal, please sign below. This document will then be the record of agreement

Signed
Print Name

15.  “THE AGENCY” DECLARATIONS

I declare that I have read and understood “The Agency” Handbook, and that I am trained to NHS standards in all these areas, should I feel I require further training in any area, I will contact “The Agency”.

The information contained within this application is to the best of my knowledge, a true and complete account, including but not limited to my professional history and criminal convictions. In addition, I give permission to “The Agency” to have access to my medical records pertinent to my immunisations and blood test history.

I duly authorise “The Agency” or its agents/nominated third parties to verify the information that i have provided, as required, and in the common interests of patient safety. In Addition I agree that “The Agency” may forward to authorised recipients, and in strictest confidence, confidential details held on my file in relation to my registration, employment and/or Occupational Health Status.

In addition I acknowledge receipt of “The Agency” Terms and Conditions and “The Agency” Handbook and confirm I will abide by the contents of both documents.

I declare that all of the information contained within this application is true and is not in any way intended to mislead.

I agree that any false or misleading information, or if I do not give relevant information now or in the future, may result in termination of an assignment without notice.

I declare that I will notify “The Agency” of any changes to my circumstances immediately. Including but not limited to changes relating to any clinical complaints or my clinical competency, criminal investigations or changes to my occupational health or professional registration status.

I confirm I understand that I am registering with “The Agency”

Signed
Print Name
Date