TLA Registration Update

Date(Required)

Applicant Name(Required)

First Middle Last

Date of Birth(Required)

NI Number(Required)

Professional Registration Number(Required)

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 Handbook. I have received, read and understood the terms and conditions of engagement of The Locum Agency. I understand that my ID Badge must be visible at all times during a Locum Agency assignment and that if I leave The Locum Agency 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 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 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

I agree for The Locum Agency 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 The Locum Agency 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 The Locum Agency should I be subject to any investigation or Fitness to Practice whilst registered.(Required)

I agree

Next of Kin: Name(Required)

First Last

Relationship(Required)

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

Passport Number(Required)

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

Passport Expiry Date(Required)

Are you an EU Citizen?(Required)

Yes

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.) 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 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(Required)

I agree

I give The Locum Agency permission to apply for my references for the purpose of obtaining employment.(Required)

I agree

Ethnicity(Required)

If other, please specify(Required)

Criminal Record Declaration

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.(Required)

Yes

If Yes, please provide details(Required)

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 agree(Required)

Applicants Name(Required)

First Last

Applicants Signature(Required)

Date(Required)