Department | TLA |
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Place of Interview | NA |
Date of Interview | 29/12/2023 |
Personal Details | |
Applicant Name | Ammara Moman |
Date of Birth | 16/04/1989 |
Marital Status | Married |
Do you hold a driving license valid for use within the UK? | No |
National Insurance Number | TJ433584A |
Do you wish to register as a limited company? | No |
I confirm that I have received and read the Key Information Document | 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 | I Agree |
I confirm that I give my permission to The Locum Agency to share my data with Total Assist Recruitment | I Agree |
Grade/Band | 2 |
Specialty | Pharmacy |
Next of Kin | |
Name | Aqeel Ahmed |
Relationship | Husband |
Contact Number | +923330735955 |
Address | Tahir heart accomodation, flat no B2 Dar up fazal sharqi Rabwah, Punjab 35460 Pakistan Map It |
Nationality | |
Do you hold a British Passport? | No |
Are you an EU Citizen? | No |
Other | NA |
Passport Number | NA |
Passport Expiry Date | 11/09/2028 |
UK Residency Visa | Yes |
UK Residency Visa Expiry Date | 11/09/2028 |
Should you hold any other Visa or residency permit, please provide the information below: | I have a valid BRP card on which I have granted work permitted in UK. I am sending the copy of BRP. The system is not accepting my passport expiry date 00/00/0000 I don’t have a valid pakistani passport instead of that I have my BRP card and my permission to stay in this country will expire on 11/09/2028 that’s why I have mentioned that date in passport expiry field. |
Current Address | 51 Somerset Close New Malden, Surrey KT3 5RG United Kingdom Map It |
Mobile Phone | +447930385643 |
Applicant Email Address | Email hidden; Javascript is required. |
Availability for Work | |
Availability to start work | 01/02/2023 |
Availability over the next 12 months | Ongoing |
Which part of the UK do you prefer to work in? |
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Declarations | DeclarationsIn 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: |
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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 | ![]() |
Professional Details | |
Professional Registration Number | NA |
Child Protection / Venerable Adults level 2/3 | 01/01/2023 |
Handling Complaints | 01/01/2023 |
Fire Procedures | 26/12/2023 |
Handling Violence & Aggression | 01/01/2023 |
COSHH & RIDDOR | 25/12/2023 |
Infection Control & Prevention | 01/01/2023 |
Lone Worker Training | 01/01/2023 |
Health & Safety | 01/01/2023 |
Risk Incident Reporting | 01/01/2023 |
Moving & Handling | 01/01/2023 |
The Caldicott Protocols | 01/01/2023 |
Basic Life Support | 01/01/2023 |
Advanced Life Support | 01/01/2023 |
Have you been appraised within the last 12 months? | No |
Vaccine History | |
Have you received the influenza vaccine? | No |
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 passport | ![]() |
Employment History | Can 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) | Lajna Immallah Uk (charity organisation) |
Position Held (Employer 1) | Secretary Nasirat |
Location (Employer 1) | London |
Tel Number (Employer 1) | 07519223650 |
Date From (Employer 1) | 01/11/2023 |
Date To (Employer 1) | 29/12/2023 |
Employer name (2) | Lajna Immallah UK (charity organisation) |
Position Held (Employer 2) | Sec. health & fitness |
Location (Employer 2) | London |
Tel Number (Employer 2) | 07519223650 |
Date From (Employer 2) | 01/04/2021 |
Date To (Employer 2) | 31/10/2023 |
Employer name (3) | Tahir Heart Institute |
Position Held (Employer 3) | Clinical Phamacist |
Location (Employer 3) | Pakistan |
Tel Number (Employer 3) | 07922139201 |
Date From (Employer 3) | 11/09/2014 |
Date To (Employer 3) | 17/03/2020 |
Professional Referees | You 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 | Dr. Saira Arib |
Email of First Referee | Email hidden; Javascript is required. |
Address of First Referee | 81 Cranbourne Avenue Surbiton, Surrey KT6 7JR United Kingdom Map It |
Phone of First Referee | 07519223650 |
Known Capacity of First Referee | Acting president of Lajna Immallah Surbiton |
Name of Second Referee | Dr. Saira Arib |
Email of Second Referee | Email hidden; Javascript is required. |
Address of Second Referee | 81 Cranbourne Avenue Surbiton, Surrey KT6 7JR United Kingdom Map It |
Phone of Second Referee | 07519223650 |
Known Capacity of Second Referee | Acting president of Lajna Immallah Surbiton |
Signature to apply for references | |
I give Total Assist Recruitment permission to forward my CV to agreed clients for the purpose of obtaining employment. |
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Equal Opportunities Policy |
Equal Opportunities PolicyAs 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 | Asian |
Criminal Record Declaration | No |
Have you ever had an Enhanced Disclosure Barring Service Check (previously DBS check) ? | No |
Consent | ![]() |
Applicants Name | Ammara Moman |
Applicant's Signature | |
For Office Purposes Only | THE F2F OFFICER MUST COMPLETE THE BELOW BEFORE LEAVING THE MEETING. |