Registration Form Update

Department

Date(Required)

Applicant Name(Required)

First Middle Last

Verified by Passport/ID

Date of Birth(Required)

NI Number(Required)

Professional Registration Number(Required)

Grade/Band(Required)

I confirm that Total Assist have my permission to request and obtain copies of payslips from my employer/ umbrella company/ personal service company and have my permission to make this available to third parties(Required)

I agree

I understand that any personal data held by Total Assist is liable to be inspected by the Care Standards Commission and/or any other authorised 3rd party including for any audits. Please select below if you do/do not agree for your personal data to be made available to any 3rd party without direct supervision from a member of staff from Total Assist or myself being present.(Required)

I agree

I agree to give Total Assist Recruitment permission carry out online DBS checks both annually or as required.(Required)

I agree

I have received, read and understood, and agree to abide by the contents of the Total Assist Recruitment Locums Handbook. I have received, read and understood the terms and conditions of engagement of Total Assist. I understand that my ID Badge must be visible at all times during a Total Assist Group Recruitment assignment and that if I leave Total Assist that I must Hand back my identity badge. All patient records should be kept confidential in line with the Data Protection Act 2018/GDPR. I also agree not to disclose to any confidential information to any 3rd Party without prior written consent.(Required)

I confirm

I confirm that Total Assist Group have my permission to generate and complete my share code check for my right to work(Required)

I confirm

I agree for Total Assist to complete checks on my professional registration licence where required.(Required)

I agree

I agree that I will maintain my Right to Work status and inform Total Assist should this change at any stage of my registration.(Required)

I agree

I agree that I will adhere to the restrictions of my Right to Work status where applicable.(Required)

I agree

I agree to inform Total Assist should I be subject to any investigation or Fitness to Practice whilst registered.(Required)

I agree

Next of Kin

Next of Kin Name(Required)

First Last

Relationship(Required)

Next of Kin Contact Number(Required)

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Do you hold a British or Irish Passport?(Required)

Yes

Are you an EU citizen?(Required)

Yes

Passport Number(Required)

Share Code for online Right to Work Check:(Required)

Passport Expiry Date(Required)

Do you hold any of the following?

Working Holiday Visa

UK Residency Visa

Student Visa

Working Permit

Working Holiday Visa Expiry Date(Required)

UK Residency Visa Expiry Date(Required)

Student Visa Expiry Date(Required)

Working Permit Expiry Date(Required)

Current Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Contact Number(Required)

Applicant Email Address(Required)

Declarations

In line with the Government legislation under the terms of the “Working Time Regulations” we recommend that your working hours should not exceed 48 hours per week (averaged over a 17 week period.)(Required)

I confirm that I wish to work more than 48 hours per week

Should you wish to waive this right, please confirm my ticking above: *

I confirm that Total Assist have my permission to forward my CV and personal data (for e.g. occupational health details, DBS check) for vacancies that satisfy my requirements as stated above and I give permission to check my DBS online service annualy.(Required)

I agree

I give Total Assist permission to forward my CV to agreed clients for the purpose of obtaining employment. *(Required)

I agree

I give Total Assist permission to apply for my references for the purpose of obtaining employment. *(Required)

I agree

Equal Opportunities Policy

As an Equal Opportunities employer the organisation welcomes applications from suitably qualified persons from all sections of the community. The organisation is committed to achieving a working environment which provides equality of opportunity and freedom from discrimination on the grounds of race, nationality, religion, gender, class, family responsibilities, marital status, sexual orientation, age, disability or special need.
The Directors believe in best practice in Equal Opportunities on the grounds of morality, good business practice and awareness that certain kinds of discrimination are unlawful. This is a key employment value to which all employees and candidates are expected to give their support.
To ensure that the policy is effective it is essential that detailed monitoring is carried out, which necessitates the collection of information. The information on this form will be kept confidential and will not be used by those involved in the selection procedure and is for statistical purposes only and will not form part of any job application.

Ethnicity(Required)

Please Specify(Required)

Criminal Record Declaration(Required)

Yes

Under the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, applicants for locum medical posts are not entitled to withhold information about convictions which for other purpose are ‘spent’. Therefore you are to inform Total Assist Healthcare Group in writing of any convictions for criminal offences past in the future.

Please provide details(Required)

Applicant's Signature(Required)

Date(Required)