DepartmentTLA
Place of InterviewTelephone
Name of InterviewerDanny Miller
Interviewer Email AddressEmail hidden; Javascript is required.
Date of Interview08/07/2024
Personal Details
Applicant NameAmelia Poppy Carew Elwell
Date of Birth07/09/1995
Marital StatusSingle
Do you hold a driving license valid for use within the UK?Yes
National Insurance NumberPA602593B
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/Band7-8
SpecialtyRotation - prescribing qualification focus on cardiology
Next of Kin
NameRosemary Elwell
RelationshipMother
Contact Number07950861710
Address735 Welford Road
Leicester
Leicester, Leicestershire LE2 6HX
United Kingdom
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Nationality
Do you hold a British Passport?Yes
Passport Number140967155
Passport Expiry Date23/05/2033
Current Address735 Welford Road
Leicester
Leicester, Leicestershire LE2 6HX
United Kingdom
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Mobile Phone07905124774
Applicant Email AddressEmail hidden; Javascript is required.
Availability for Work
Availability to start work08/07/2024
Availability over the next 12 monthsTBC
Which part of the UK do you prefer to work in?
  • East Midlands
  • North West
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 Number2227330
Have you been appraised within the last 12 months?Yes
Name of AppraiserJoanna McNeil
Position and Grade of AppraiserClinical lead medicine - band 8
Professional Registration Number of Appraiser2219276
Next appraisal due?11/07/2024
Date of last appraisal10/07/2023
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 vaccine27/09/2023
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?Yes
If Yes please attach your COVID vaccine passportIf Yes please attach your COVID vaccine passport
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)South Tyneside and Sunderland foundation trust
Position Held (Employer 1)Band 6 pharmacist
Location (Employer 1)Harton Ln, South Shields NE34 0PL
Tel Number (Employer 1)0191 404 1000
Date From (Employer 1)01/09/2020
Date To (Employer 1)06/01/2023
Employer name (2)Queen Elizabeth I hospital Gateshead
Position Held (Employer 2)Band 7 pharmacist
Location (Employer 2)Queen Elizabeth Ave, Gateshead NE9 6SX
Tel Number (Employer 2)0191 482 0000
Date From (Employer 2)09/01/2023
Date To (Employer 2)22/12/2023
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 RefereeNicholas Lawson
Email of First RefereeEmail hidden; Javascript is required.
Address of First RefereeHarton Ln, South Shields NE34 0PL
Tyne and Wear South Shields
United Kingdom
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Phone of First Referee0191 404 1000 (switch board ask to be put through to pharmacy)
Known Capacity of First Referee9-5 monday - friday
Name of Second RefereeJoanna Mc Neill
Email of Second RefereeEmail hidden; Javascript is required.
Address of Second RefereeQueen Elizabeth Ave, Gateshead NE9 6SX
tyne and wear gateshead
United Kingdom
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Phone of Second Referee0191 482 0000 (ask switch board for Joanna McNeill)
Known Capacity of Second Referee9-5 mon-fri
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 SelectWhite
Criminal Record DeclarationNo
Have you ever had an Enhanced Disclosure Barring Service Check (previously DBS check) ?Yes
Disclosure Number0016660491374
Date of Disclosure06/06/2019
Consent I agree
Applicants NameAmelia Poppy Carew Elwell
Applicant's Signature
For Office Purposes OnlyTHE F2F OFFICER MUST COMPLETE THE BELOW BEFORE LEAVING THE MEETING.