APPLICATION FORM

IN CONFIDENCE

Please complete this form using black ink or typescript as it will be photocopied. It is important that you complete all the details to enable us to process your application efficiently and to meet our Governance Standards.

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Personal Details

Surname (BLOCK LETTERS)

______

Forenames

______

Title (Dr, Mr, Mrs, Miss, Ms etc.)

______

Surname at Birth, if different

______

NI Number

______

Permanent Address (BLOCK LETTERS)

Postcode

Telephone Number(daytime)

(evening)

(mobile)

Fax Number

Email Address:

Next of kin details

Name

Address

Postcode

Telephone number

Mobile number

Relationship to you

Date you qualified as a General Practitioner?......

GMC Number: ......

Do you require a work permit to work in the UK?

Yes No 

Are you free to remain and work in the UK?

Yes No 

Do you have an NHS Smartcard?

Yes No 

If yes what is the Smartcard Number?

......

Which Area Performers list are you registered on?

......

Date joined Area Performers list ......

Have you ever had or do you currently have any outstanding restrictions on your clinical practice (eg GMC or Area Team restrictions/suspensions) or any performance pending or ongoing investigations? If yes please explain in your cover letter/email.

□ Yes□ No

Date of last GP Appraisal ......

Accredited GP Trainer/Associate Trainer

□ Yes□ No

Have you ever worked for Herts Urgent Care through an Agency?

□ Yes□ No

Do you work for any other Out of Hours providers?

□ Yes□ No

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RELEVANT CLINICAL EXPERIENCE

What qualities, knowledge and experience can you bring to the post?

REFERENCES

Please provide details of two referees:

I understand that Herts Urgent Care may contact my current surgery and the Performers list and or the LMC for a reference having received the application form. If I don’t have a current surgery they may contact up to 4 previous employers

Signed......

REHABILITATION OF OFFENDERS ACT 1974 & RIGHT TO WORK IN THE UK

As the post you are applying for involves direct contact with people who are receiving a health service, you are not entitled to withhold information about convictions which are spent under the Act. Any information given will be completely confidential, and will be considered only in relation to an application for positions to which the Order applies.

Have you any previous convictions or have you any hearings pending:Yes No 

if yes, please give details

Are you entitled to work in the UK and can you produce right to work documents? Yes No 

DE DECLARATION

The details given on this application are correct to my knowledge and belief. I understand that my application may be rejected or that I may be dismissed for withholding relevant details or giving false information. I also understand that the appointment will be subject to satisfactory references.

SIGNATURE: ...... DATE: ......

Attached with this application form

Copy of current CV(required if full clinical history is not provided in the application form)

 Copy of Immunisation report

Copy of Indemnity Certificate covering OOHs

Copy of current DBS certificate - dated within the last 2 years

Evidence of Adult Safeguarding Level 2

 Evidence of Child Safeguarding Level 2

 Evidence of Child Safeguarding Level 3

Copy of current BLS certificate

Copy of Passport

As part of the application process you will be required to provide original evidence of your right to work in the UK – Please bring the original document to induction.

PAYMENT DETAILS

Name of Bank:
Payee Account Name
Payee Account Number
Payee Sort Code

Are you in the NHS Pension Scheme? Yes No 

If yes, please provide your superannuation rate below

HERTS URGENT CARE
Equal Opportunities Recruitment Monitoring Form – Strictly Confidential

Herts Urgent Care (HUC) is committed to promoting fairness and eliminating discrimination from recruitment and selection practices. We will ensure that no job applicant or employee receives less favourable treatment either directly or indirectly, on the grounds of age, race, disability, gender, marital status, religion or faith or sexual orientation.

To monitor and audit the effective delivery of this commitment, HUC requires all applicants to provide information asked for in this monitoring form. This will only be used for this purpose, and will form no part of the interview process and will be treated in strict confidence.

The form will be detached from your application form and held separately in Human Resources to help monitor the diversity of applications we receive. This will enable us to develop appropriate policies and procedures in respect of diversity and equal opportunities.

Name: Date:

Position applied for:

1.Gender: Male Female

2.Date of birth:

3.Marital status: Married Single Divorced Other

(Please specify …………………………)

4.Nationality:

5.How would you describe your ethnic origin?

Asian or Asian British
 Bangladeshi
 Indian
 Pakistani
 Any other Asian background
Black or Black British
 African
 Caribbean
 Any other Black background / Mixed
 White & Asian
 White & Black African
 White & Black Caribbean
 Any other mixed background
White
 British
 Irish
 Any other White background / Other Ethnic Group
 Chinese
 Any other ethnic group
 I do not wish to disclose my ethnic origin

6.Disability is defined by the Equality Act (2010) as;

A physical or mental impairment, which has a substantial and long-term adverse effect on a person’s ability to carry out normal day-to-day activities. The disability could be physical, sensory or mental and must be expected to last at least 12 months

Are you a disabled person as defined by the Equality Act (2010) ? Yes No

7.How would you describe your religion or belief?

Christian Buddhist Hindu Jewish

Muslim Sikh None Prefer not to say

Other (please specify ……………………………………………………………………)

8.What of the following describes your sexual orientation?

Bi-sexual Gay Heterosexual Lesbian

Other Prefer not to disclose

Thank you for completing this form. Please return it with your application.

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