Application form

Phone

Personal details

First name

Last name

GMC no.

Date of birth

Smartcard ID

Next of kin (name, relationship & contact no.)

Right to work

Passport no.

Nationality

Visa status (if applicable)

I understand that if I am on a student visa, I can only work for 20 hours per week during term time. I understand that I have a responsibility to monitor this. In addition, if my position changes, I must inform locum.co.uk.

References

If your referee details are not on your CV, please provide here:

Name of first referee

Organisation

Address

Contact no.

Name of second referee

Organisation

Address

Contact no.

Declaration of criminal records

Do you have any convictions, cautions, reprimands or warnings?

Yes

if yes, please list your criminal convictions and the dates

Are you subject t any pending proceedings?

Yes

The information you give will be treated in confidence and will only be taken into account where, in the reasonable opinion of the Company, the offence is relevant to the post you have applied for. Certain types of employment and certain professions are exempt from The Rehabilitation of Offenders Act 1974 and in those cases, particularly where the employment is sought in relation to positions working with children or vulnerable adults details of all criminal convictions, both spent and unspent, must be given. Failure to declare a conviction may require us to exclude you from our register or terminate the assignment if the offence is not declared but later comes to light.

Professional conduct

Are you currently or have you previously been subject to any suspension, investigation, serious complaint or dismissal by an employer, professional body or regulator?

Yes

if yes, please give details

Declarations

The working time regulations stipulate that employers will limit your average weekly working time to 48 hours; should you wish to waive this right, please confirm :

Yes, I wish to waive this right

I declare that all information given, as well as any documentation provided, is accurate. I agree that if I have given any false information or have refused to submit any relevant information, this may lead to the application being declined or instant dismissal from any assignment. I declare that I have received and read the terms and conditions and accept the applicable terms of engagement. I acknowledge that my personal details will be stored and handled correctly by locum.co.uk in accordance with General Data Protection Regulations. I agree that my personal details, including all documentation, may be made available for audit by customers and clients of locum.co.uk and their appointed auditors. I authorise locum.co.uk to disclose any convictions stated on a CRB / DBS disclosure or other police check to any potential employers in accordance with the internal policy of locum.co.uk, the CRB Code of Practice and the Rehabilitation of Offenders Act.

I confirm that I have read and agree to the above declaration

Thanks for submitting!