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DepartmentTLA
Place of InterviewLocum pharmacist
Date of Interview23/11/2023
Personal Details
Applicant NameSarah Amin
Date of Birth29/01/1982
Marital StatusSingle
Do you hold a driving license valid for use within the UK?Yes
National Insurance NumberJH754341B
Do you wish to register as a limited company?No
I confirm that I have received and read the Key Information DocumentYes
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 partiesI Agree
I confirm that I give my permission to The Locum Agency to share my data with Total Assist RecruitmentI Agree
Grade/Band7
SpecialtyPHARMACY
Next of Kin
NameGehad Bakry
Relationshippartner
Contact Number+447477777939
Address424 Hurtsway walk
London, london W11 1wE
United Kingdom
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Nationality
Do you hold a British Passport?Yes
Passport Number554151190
Passport Expiry Date23/07/2028
Current Address47 levett House
Denman Avenue
London, London UB2 4FU
United Kingdom
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Mobile Phone+447931766927
Applicant Email AddressEmail hidden; Javascript is required.
Availability for Work
Availability to start work23/11/2023
Availability over the next 12 monthsOngoing
Which part of the UK do you prefer to work in?
  • London
Declarations

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:
  • 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
Consent I agree
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
Professional Details
Professional Registration Number2061491
Have you been appraised within the last 12 months?No
Position and Grade of AppraiserSenior haematology Pharmacist
Vaccine History
Have you received the influenza vaccine?No
Would you consider having the influenza vaccine, if offered to you?No
Have you received both doses of either a Pfizer BioNTech or Oxford/AstraZeneca COVID vaccine?Yes
If Yes please attach your COVID vaccine passportCoronavirus-COVID-19-records1.pdf
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)Hillingdon PCN
Position Held (Employer 1)GP pharmacist
Location (Employer 1)London
Date From (Employer 1)18/09/2023
Date To (Employer 1)13/11/2023
Employer name (2)Locum Pharmacy
Position Held (Employer 2)Pharmacist
Location (Employer 2)London
Tel Number (Employer 2)07944678830
Date From (Employer 2)03/07/2023
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 RefereeKimberley redman
Email of First RefereeEmail hidden; Javascript is required.
Address of First RefereeHillingdon PCN
Link 1A, 1 Civic centre
high street UB8 1UW
United Kingdom
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Name of Second RefereeSobha Sharma
Email of Second RefereeEmail hidden; Javascript is required.
Address of Second RefereeUnited Kingdom
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Phone of Second Referee07944678830
Known Capacity of Second RefereePharmacy owner
Signature to apply for references
I give Total Assist Recruitment permission to forward my CV to agreed clients for the purpose of obtaining employment.
  • I agree
Equal Opportunities Policy

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 SelectAsian
Criminal Record DeclarationNo
Have you ever had an Enhanced Disclosure Barring Service Check (previously DBS check) ?Yes
Consent I agree
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.
Applicants NameSarah Amin
Applicant's Signature
For Office Purposes OnlyTHE F2F OFFICER MUST COMPLETE THE BELOW BEFORE LEAVING THE MEETING.