TLA Registration Form HiddenDepartment Place of Interview(Required) Name of Interviewer First Last Interviewer Email Address Date of Interview DD slash MM slash YYYY Personal DetailsApplicant Name(Required) First Middle Last Applicant Maiden Name First Middle Last Date of Birth(Required) DD slash MM slash YYYY Marital Status(Required) Single Married Divorced Widowed Do you hold a driving license valid for use within the UK?(Required) Yes No National Insurance Number(Required) Do you wish to register as a limited company?(Required) Yes No Company Name Company Nuimber I confirm that I have received and read the Key Information Document(Required) Yes I confirm that The Locum Agency 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 The Locum Agency 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 The Locum Agency or myself being present.(Required) I Agree I agree to give The Locum Agency 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 Locum Agency Staff Handbook. I have received, read and understood the terms and conditions of engagement of TLA. I understand that my ID Badge must be visible at all times during a TLA assignment and that if I leave TLA 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 The Locum Agency have my permission to generate and complete my share code check for my right to work(Required) I Agree I confirm that I give my permission to The Locum Agency to share my data with Total Assist Recruitment(Required) I Agree Grade/Band(Required) Specialty(Required) Next of KinName(Required) First Last Relationship(Required) Contact Number(Required)Address(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country NationalityDo you hold a British Passport?(Required) Yes No Evidence of all passports and visas are required. Please enclose photocopies with this application form and make sure you bring the originals to your interview. To work in the NHS you will be expected to communicate proficiently in English and this will be assessed at your interview.Are you an EU Citizen?(Required) Yes No Other(Required) Passport Number(Required) Share Code for online Right to Work Check:(Required) Passport Expiry Date(Required) DD slash MM slash YYYY Working Holiday Visa Yes Working Holiday Visa Expiry Date(Required) DD slash MM slash YYYY UK Residency Visa Yes UK Residency Visa Expiry Date(Required) DD slash MM slash YYYY Student Visa Yes Student Visa Expiry Date(Required) DD slash MM slash YYYY Working Permit Yes Working Permit Expiry Date(Required) DD slash MM slash YYYY Should you hold any other Visa or residency permit, please provide the information below:Current Address(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mobile Phone(Required)Home PhoneWork PhoneApplicant Email Address(Required) Availability for WorkAvailability to start work(Required) DD slash MM slash YYYY Availability over the next 12 months(Required)Ongoing1-2 Weeks3-4 Weeks4-6 Weeks6-12 WeeksOdd DaysNights & WeekendTBCWhich part of the UK do you prefer to work in?AnywhereLondonEast MidlandsWest MidlandsNorth EastNorth WestSouth WestSouth EastWalesNorthern IrelandScotlandOffshoreDeclarations 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.)Should you wish to waive this right, please confirm my ticking below:(Required) I confirm that I wish to work more than 48 hours per week I understand that information give on this form will be stored and handled by The Locum Agency in accordance with the Data Protection Act 1988, however, I agree that this information may be made available for audit by the relevant Government organisations e.g. CCS / CPP Framework. Data Protection Act 1998 / The General Data Protection Regulations 2018 In relation to the Data Protection Act 1998 / The General Data Protection Regulations 2018, you agree to the processing of personal data for the purposes of the recruitment process as well as for future potential employment arrangements for the purposes of calculating your remuneration and maintaining records on attendance, health, discipline and grievances such as are necessary for the performance of your contract. For further information, please see the Information Commissioner's website ww.dataprotection.gov.uk, from which the above guidance is reproduced. I acknowledge that I have been given a copy of the terms and conditions of service issued by The Locum Agency, which is mine to keep and further more that I have read those terms and conditions and agree to abide by them. I am not aware of any condition, medical or otherwise which would affect or limit my employment or performance, other than those declared in my Pre-employment Health Questionnaire From and I am fit for work. I authorise The Locum Agency to disclose any convictions to any potential employers in accordance with the DBS Code of Practice and the Rehabilitation of Offenders. I declare that the details given by me on this application form are correct to the best of my knowledge and belief. I understand that if I have given any information which is false, or I withhold any relevant information, this may lead to my application being rejected, or if already appointed, to my dismissal, as well as a claim for recovery of any payments I have received, together with a claim for loss of profit to The Locum Agency. I also give The Locum Agency Permission to apply and to check my DBS certificate on the UK DBS update service annually. I give The Locum Agency Permission if required to conduct any relevant right to work checks Via the Government websites.Signature(Required)Consent(Required) I agreeI confirm that The Locum Agency 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. I also give permission to check my DBS online service annually Professional DetailsProfessional Registration Number(Required) QualificationsConfiguration RequiredUse the Nested Form and Summary Fields settings to choose the form and fields to display in this Nested Form field.Please complete in the table provided all professional qualifications held, including Post Graduate Diploma / Courses etc. Note that professional qualifications and training will be verified. Child Protection / Venerable Adults level 2/3 DD slash MM slash YYYY Handling Complaints DD slash MM slash YYYY Fire Procedures DD slash MM slash YYYY Handling Violence & Aggression DD slash MM slash YYYY COSHH & RIDDOR DD slash MM slash YYYY Infection Control & Prevention DD slash MM slash YYYY Lone Worker Training DD slash MM slash YYYY Health & Safety DD slash MM slash YYYY Risk Incident Reporting DD slash MM slash YYYY Moving & Handling DD slash MM slash YYYY The Caldicott Protocols DD slash MM slash YYYY Basic Life Support DD slash MM slash YYYY Advanced Life Support DD slash MM slash YYYY Have you been appraised within the last 12 months?(Required) Yes No Name of Appraiser First Last In order to work within the NHS you will need to be appraised annually by a Senior Practitioner of the same discipline, this person will become your “appraiser”. Please give the details of the Senior Practitioner you have made arrangements with to act as your appraiser.Position and Grade of Appraiser Professional Registration Number of Appraiser Next appraisal due? DD slash MM slash YYYY Date of last appraisal DD slash MM slash YYYY Appraisal Statement - Select if you agree with the following statements I confirm the appraisal was within an "Approved NHS Appraisal System" and includes 360 degree feedback as well as feedback from patients. I confirm that I maintain a written portfolio of my professional experience and attendance at proffessional development courses, which also includes a written and agreed "Personal Development Plan" as agreed at the appraisal. Vaccine HistoryHave you received the influenza vaccine?(Required) Yes No Date of influenza vaccine(Required) DD slash MM slash YYYY Would you consider having the influenza vaccine, if offered to you?(Required) Yes No Have you received both doses of either a Pfizer BioNTech or Oxford/AstraZeneca COVID vaccine? Yes No If Yes please attach your COVID vaccine passport(Required) Drop files here or Select files Max. file size: 48 MB. Employment HistoryCan you please provide details in the boxes below of your last 3 years employment (most recent first). If there are any gaps of 3 month or more it is important that you explain the reason why in the box below.Employer name (1) Position Held (Employer 1) Location (Employer 1) Tel Number (Employer 1)Date From (Employer 1) DD slash MM slash YYYY Date To (Employer 1) DD slash MM slash YYYY Employer name (2) Position Held (Employer 2) Location (Employer 2) Tel Number (Employer 2)Date From (Employer 2) DD slash MM slash YYYY Date To (Employer 2) DD slash MM slash YYYY Employer name (3) Position Held (Employer 3) Location (Employer 3) Tel Number (Employer 3)Date From (Employer 3) DD slash MM slash YYYY Date To (Employer 3) DD slash MM slash YYYY Professional RefereesYou are required to supply at least two work related professional referees. The 2 referees provided must be within the last 12 months and be concurrent. If you have worked at the same Hospital for the last 12 months then we require 2 referees from that Hospital. Both referees must be a Consultant or Clinical Director. (We have allocated space for additional referees to be included, should you wish to provide more than two referees you must follow the above same principle.)Name of First Referee First Last Email of First Referee Address of First Referee Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone of First RefereeKnown Capacity of First Referee Name of Second Referee First Last Email of Second Referee Address of Second Referee Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone of Second RefereeKnown Capacity of Second Referee Signature to apply for references(Required)Please sign to allow us to contact your referees immediately.I give Total Assist Recruitment permission to forward my CV to agreed clients 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. *Please Select(Required)AsianBlackWhiteOtherPlease Specify Criminal Record Declaration(Required) Yes No 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 The Locum Agency in writing of any convictions for criminal offences past in the future.Please Provide Details(Required)Have you ever had an Enhanced Disclosure Barring Service Check (previously DBS check) ?(Required) Yes No If you haven’t completed a DBS (previously DBS) check through The Locum Agency, or if the last one was completed over 12 months ago, you are required to complete the attached DBS form provided so that we may undertake an Enhanced DBS check on your behalf. You will not be place in employment without having completed a current DBS check. Please ensure you enclose all original documentation (e.g. passport) as photocopies will not be accepted and your form will be returned to you.Disclosure Number Date of Disclosure DD slash MM slash YYYY Consent(Required)I give The Locum Agency permission to forward my CV to agreed Clients for the purpose of obtaining employment. I hereby confirm that the information provided on my application is correct and true to the best of my knowledge and that I have not withheld any information that should be taken into account when offering me work. I understand that providing false or inaccurate information may result in the termination of any placement. I agree that I will make best endeavours to make myself aware of the Health & Safety procedures for each client I am assigned to. I declare that by signing this form I am stating that I am legally entitled or allowed to work in the United Kingdom, with or without necessary permission from the Home Office or any other relevant authority. If I have secured permission to work, I have included copies of all documentation. I also acknowledge that if it is found that I am working without the relevant permission, my employment will be terminated with immediate effect and all details passed to the relevant authorities. I agree that The Locum Agency retains the right to hold this registration form and any other data required to process it and pass onto any authorised third party and the details held within. I also agree to use all reasonable efforts to assist in order to comply with the Data Protection Act 1998. I confirm that I have read and understood the Terms of Engagement and the terms of the declaration and agree to be bound by them. I confirm that The Locum Agency 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. I hereby declare that at no time will I divulge to any person, nor use for my own or any other person’s benefit, any confidential information in relation to the Client or the Company (The Locum Agency) or in relation to any of their employees, business affairs, transactions or finances which I may acquire during the term of my agreement with the Company (The Locum Agency) under the Terms of Engagement. Each agency worker has a responsibility at the start of their first shift to become familiar with the Client’s general policies including, without limitation, those relating to Crash Call Procedures, the Hot Spot Mechanism for alerting security staff that an individual is in trouble, Fire Policy and the Violent Episode Policy. For the purposes of the Working Time Regulations 1998 (as amended) I consent to work in excess of an average of 48 hours per week, averaged over 17 weeks. I understand that I may withdraw this consent by giving The Locum Agency not less than three months’ notice at any time. In addition, I also consent to work in excess of the maximum number of hours permitted to work at night under the directive. Please note you are under no obligation to sign either declaration. By signing above I confirm to all the above statements within this document. I confirm I have received, read and understood, and agree to abide by the contents of the The Locum Agency Locums Handbook. I confirm I have received, read and understood the terms and conditions of engagement of The Locum Agency. I can confirm I understand that my ID Badge must be visible at all times during a The Locum Agency Recruitment assignment and that if I leave The Locum Agency that I must Hand back my identity badge. I confirm my personal data can be made available to any 3rd party without direct supervision from a member of staff from The Locum Agency or myself being present. I agreeApplicants Name(Required) First Middle Last Applicant's Signature(Required)Interviewer's Name First Last Interviewer's SignatureFor Office Purposes OnlyTHE F2F OFFICER MUST COMPLETE THE BELOW BEFORE LEAVING THE MEETING.Did the candidate have a good command of the English language? Yes No Was the candidate pleasant and polite? Yes No Was the candidate courteous and helpful? Yes No Are you happy to offer this candidate work on the basis of this interview? Yes No EmailThis field is for validation purposes and should be left unchanged.
