Frimley Park Hospital Foundation NHS Trust/Surrey Heath CCG HR Department

ESR Starter/ Appointment Form

IMPORTANT THESE DETAILS ARE REQUIRED FOR PAY PURPOSES FAILURE TO RETURN THE FORM PROMPTLY WILL RESULT IN PAYMENT OF YOUR SALARY BEING DELAYED. Please complete Part A below, and hand this form to your manager on your first working day before returning to the HR Department. All information will be treated in strict confidence.

PART A – PERSONAL DETAILSPLEASE PRINT CLEARLY
TITLE: / MARITAL STATUS: / MAIDEN NAME :
SURNAME : / OTHER PREVIOUS SURNAME :
GIVEN FORENAMES : / FULL NAME OFNEXT OF KIN:
PREFERRED/ ‘KNOWN AS’ NAME:
DATE OF BIRTH:
HOME ADDRESS :
POSTCODE :
EMAIL ADDRESS: / RELATIONSHIP:
ADDRESS:
POSTCODE :
HOME TEL NO :
MOBILE NO:
ADDRESS WHILE AT FPH/SURREY CCG IF DIFFERENT
FROM ABOVE : / HOME TEL NO:
MOBILE TEL NO:
WORK TEL NO:
POSTCODE : / Your NATIONAL INSURANCE NUMBER :
TEL NO.:
BANK/BUILDING SOCIETY DETAILS
ACCOUNT NAME & NO / ADDRESS OF BANK/BUILDING SOCIETY
SORT CODE
DO YOU CURRENTLY HAVE ANOTHER JOB(S) WITH FRIMLEY PARK HOSPITAL/SURREY CCG? YES/NO
IF YES, PLEASE STATE YOUR: / PERSONAL NUMBER(S)
DEPARTMENT(S)
JOB TITLE(S)
YOUR PRESENT CIRCUMSTANCES – please tick as appropriate
/ A – This is my first job since last 6 April and I HAVE NOT been receiving taxable Jobseeker’s Allowance, Employment and Support Allowance or taxable Incapacity Benefit or a state or occupational pension
/ B – This is now my only job, but since last 6 April I HAVE had another job, or have received taxable Jobseeker’s Allowance, Employment and Support Allowance or taxable Incapacity Benefit. I do not receive a state or occupational pension
/ C- I have another job or receive a state or occupational pension
STUDENT LOANS
/ If you left a course of UK Higher Education before last 6 April and received your first UK Student Loan instalment on or after 1 September 1998 and you have not fully repaid your Student Loan, tick box
(do not tick box if you are repaying your UK Student Loan by agreement with the UK Student Loans Company to make monthly payments through your bank or building society account)

PART B - IF YOU CURRENTLY WORK ELSEWHERE IN THE NHS, PLEASE GIVE DETAILS OF YOUR CURRENT JOB. IF YOU HAVE PREVIOUSLY WORKED IN THE NHS PLEASE GIVE DETAILS OF YOUR LAST 2 JOBS (INCLUDING ANY AT FRIMLEY PARK/SURREY CCG).

NAME OFNHS TRUST/HA / ADDRESS OF TRUST/HA /

POST OR GRADE

/ FULL
/PART
TIME / FROM
MM/YY / TO
MM/YY / PENSION
SCHEME MEMBER?
YES/NO
YES/NO
YES/NO
YES/NO

NHS Pension Scheme ID Number:______

PLEASE NOTE:

  1. You will automatically join the NHS Pension Scheme unless you decide to opt out. If you do not wish to join the scheme please print the Opting Out form SD502 from the NHS Pensions website ( complete Part 1 and send Parts 1 and 2 to the Payroll Department.
  2. If you have been a member of another occupational or personal pension scheme, it may be possible to transfer your pension rights into the NHS Pension Scheme. Please contact the Payroll Department if you wish to consider this.

I authorise the Director of Human Resources and Facilities to deduct from my salary/wage any charges which may become payable for services provided by the Trust and agreed by me on joining the Trust. I authorise use of my Bank/Building Society details for pay purposes.

I believe the particulars on this form to be correct.

Signed______Date______

Employee

Manager’s Signature: / Manager’s Name:
Date:
PART C: TO BE COMPLETED BY HR DEPARTMENT
POST START DATE : / DEPARTMENT :
TRUST START DATE : / BAND & POINT OF SCALE
ASSIGNMENT NO : / BAND START DATE :
JOB TITLE : / DBS Deduction: Standard - £6.50 for 2 months
Enhanced - £11 for 2 months
CONTRACT HOURS:
(NB: Check Hours Protection): / PAY FREQUENCY: MONTHLY
STANDARD HOURS: 37.5 / FULL-TIME SALARY:
CONTRACT TYPE : / GRADE STEP:
CONTRACT EXPIRY DATE : / ALLOWANCES :
ASSIGNMENT: PRIMARY/SECONDARY / HIGH COST AREA SUPPLEMENT: 5%
INCREMENTAL DATE: / HISTORIC ENHANCEMENTS:
PASSPORT DETAILS ENTERED INTO THE ESR: / RESIDENCY STATUS:
ESR Input / Copy to Payroll / Copy on File / Rec 1 Number / D.O.B. Verified
Signature: ______(HR Admin) Date: ______

ESR/ kmt/ Starter Form (Rec 7) - Updated September 2015

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