Department | TLA |
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Place of Interview | Zoom |
Name of Interviewer | Jose Cruz |
Interviewer Email Address | Email hidden; Javascript is required. |
Date of Interview | 10/01/2024 |
Personal Details | |
Applicant Name | Emma Louise Smith |
Date of Birth | 05/10/1990 |
Marital Status | Single |
Do you hold a driving license valid for use within the UK? | Yes |
National Insurance Number | PX999241B |
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 | 5/6 |
Specialty | Pharmacy - ACT |
Next of Kin | |
Name | Sean Tomlin |
Relationship | Partner |
Contact Number | +447927661488 |
Address | Flat B 27B Baronet Road London, London N19 0LU United Kingdom Map It |
Nationality | |
Do you hold a British Passport? | Yes |
Passport Number | 131192151 |
Passport Expiry Date | 21/04/2032 |
Current Address | 27B Baronet Road LONDON, London N17 0LU United Kingdom Map It |
Mobile Phone | +447476965075 |
Applicant Email Address | Email hidden; Javascript is required. |
Availability for Work | |
Availability to start work | 15/01/2024 |
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 | 5101140 |
Have you been appraised within the last 12 months? | No |
Vaccine History | |
Have you received the influenza vaccine? | Yes |
Date of influenza vaccine | 17/11/2023 |
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 passport | Coronavirus-COVID-19-records-21.pdf |
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) | Charing Cross Hospital |
Position Held (Employer 1) | Locum Technician - ACT |
Location (Employer 1) | Fulham Palace Rd, London W6 8RF |
Tel Number (Employer 1) | 020 3311 1234 |
Date From (Employer 1) | 09/10/2023 |
Date To (Employer 1) | 21/12/2023 |
Employer name (2) | Chelsea and Westminster Hospital |
Position Held (Employer 2) | Locum Technician - ACT |
Location (Employer 2) | 369 Fulham Rd., London SW10 9NH |
Tel Number (Employer 2) | 020 3315 8000 |
Date From (Employer 2) | 19/06/2023 |
Date To (Employer 2) | 30/09/2023 |
Employer name (3) | Moorfields Eye Hospital |
Position Held (Employer 3) | Locum Technician - ACT |
Location (Employer 3) | (City Road Campus) 162 City Road London EC1V 2PD |
Tel Number (Employer 3) | 020 7253 3411 |
Date From (Employer 3) | 10/05/2023 |
Date To (Employer 3) | 16/06/2023 |
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 | Niketa Pandya |
Email of First Referee | Email hidden; Javascript is required. |
Address of First Referee | North Middlesex Hospital Sterling Way London N18 1QX United Kingdom Map It |
Known Capacity of First Referee | Pediatric Oncology Homecare Pharmacist - band 8 |
Name of Second Referee | Raveena Nagaria |
Email of Second Referee | Email hidden; Javascript is required. |
Address of Second Referee | Chelsea and Westminster Hospital 369 Fulham Rd. London SW10 9NH United Kingdom Map It |
Phone of Second Referee | Dispensary/Gastroenterology Pharmacist |
Known Capacity of Second Referee | London |
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 | White |
Criminal Record Declaration | No |
Have you ever had an Enhanced Disclosure Barring Service Check (previously DBS check) ? | Yes |
Disclosure Number | 001694549068 |
Date of Disclosure | 20/03/2020 |
Consent | ![]() |
Applicants Name | Emma Louise Smith |
Applicant's Signature | |
For Office Purposes Only | THE F2F OFFICER MUST COMPLETE THE BELOW BEFORE LEAVING THE MEETING. |