DepartmentTLA
Place of InterviewLondon
Name of InterviewerTLA TLA
Date of Interview13/05/2024
Personal Details
Applicant NameMose Arena
Date of Birth25/04/1972
Marital StatusMarried
Do you hold a driving license valid for use within the UK?Yes
National Insurance NumberPW523804A
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/BandBAND 6
SpecialtyExpert in aseptic preparation of paediatric chemotherapy, adult, paediatric and neonatal parenteral nutrition, clinical trials medication and a centralised intravenous additive service using isolator or LFC.
Next of Kin
NameMose Arena
RelationshipPartner
Contact Number07507563400
Address31 Ridgeway Drive
Ridgeway Drive
Bromley, London BR15DG
United Kingdom
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Nationality
Do you hold a British Passport?No
Are you an EU Citizen?Yes
Passport NumberYA9551108
Passport Expiry Date02/06/2026
UK Residency VisaYes
UK Residency Visa Expiry Date13/05/2024
Working PermitYes
Working Permit Expiry Date13/05/2024
Should you hold any other Visa or residency permit, please provide the information below:

Share code
W8E Y6C 4P7

Current Address31 Ridgeway Drive
Ridgeway Drive
Bromley, London BR15DG
United Kingdom
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Mobile Phone07507563400
Applicant Email AddressEmail hidden; Javascript is required.
Availability for Work
Availability to start work01/08/2024
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
Professional Details
Professional Registration Number5015323
Child Protection / Venerable Adults level 2/301/02/2024
Handling Complaints01/02/2024
Fire Procedures08/01/2024
Handling Violence & Aggression01/02/2024
COSHH & RIDDOR01/02/2024
Infection Control & Prevention01/09/2024
Health & Safety01/02/2024
Risk Incident Reporting01/02/2024
Moving & Handling01/02/2024
Have you been appraised within the last 12 months?Yes
Name of AppraiserAlison Oliver
Position and Grade of AppraiserChief technician
Next appraisal due?10/10/2024
Date of last appraisal10/10/2023
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 History
Have you received the influenza vaccine?Yes
Date of influenza vaccine02/01/2023
Would you consider having the influenza vaccine, if offered to you?Yes
Have you received both doses of either a Pfizer BioNTech or Oxford/AstraZeneca COVID vaccine?No
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)Imperial College Healthcare NHS Trust
Position Held (Employer 1)Senior Pharmacy Technician -Cancer and Technical Services
Location (Employer 1)Fulham Palace Road, London W6 8RF
Tel Number (Employer 1)020 3311 1234
Date From (Employer 1)07/12/2019
Employer name (2)St George’s University Hospitals NHS Foundation Trust
Position Held (Employer 2)Senior Pharmacy Technician
Location (Employer 2)Blackshaw Road Tooting, London SW17 0QT
Tel Number (Employer 2)0208 672 1255
Date From (Employer 2)23/08/2024
Date To (Employer 2)29/11/2019
Employer name (3)Royal Free London NHS Foundation Trust
Position Held (Employer 3)Senior Pharmacy Technician
Location (Employer 3)Pond Street, London, NW3 2QG
Tel Number (Employer 3)020 7794 0500
Date From (Employer 3)23/08/2010
Date To (Employer 3)18/08/2023
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 RefereeMeera Patel
Email of First RefereeEmail hidden; Javascript is required.
Address of First RefereeImperial College Healthcare NHS Trust
Du Cane Road, London W12 0HS
Hammersmith Hospital London W12 0HS
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Phone of First Referee02033132685
Known Capacity of First RefereeLine Manager
Name of Second RefereeMohammed Haque
Email of Second RefereeEmail hidden; Javascript is required.
Address of Second RefereeImperial College Healthcare NHS Trust
Fulham Palace Road London W6 8RF
London W6 8RF
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Phone of Second Referee020 3311 1234
Known Capacity of Second RefereeLine manager
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 SelectOther
Please SpecifyMixed Race
Criminal Record DeclarationNo
Have you ever had an Enhanced Disclosure Barring Service Check (previously DBS check) ?No
Consent I agree
Applicants NameMose Arena
Applicant's Signature
For Office Purposes OnlyTHE F2F OFFICER MUST COMPLETE THE BELOW BEFORE LEAVING THE MEETING.