DepartmentTLA
Place of InterviewHigh wycombe
Date of Interview26/03/2024
Personal Details
Applicant NameHafifa Sajid
Date of Birth16/05/1997
Marital StatusMarried
Do you hold a driving license valid for use within the UK?Yes
National Insurance NumberPB 93 83 60 A
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/Band5/6
SpecialtyCpht
Next of Kin
NameAdnaan Rahman
RelationshipHusband
Contact Number07904381267
Address107
Rutland avenue
High wycombe, High wycombe Hp12 3jq
United Kingdom
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Nationality
Do you hold a British Passport?Yes
Passport Number536564059
Passport Expiry Date01/06/2026
Working Holiday VisaYes
Working Holiday Visa Expiry Date26/03/2024
UK Residency VisaYes
UK Residency Visa Expiry Date26/03/2024
Student VisaYes
Student Visa Expiry Date26/03/2024
Working PermitYes
Working Permit Expiry Date26/03/2024
Should you hold any other Visa or residency permit, please provide the information below:

I have clicked the above by accident and i could not click off so i put todays date in i do apologise.

Current Address107
Rutland avenue
High wycombe, High wycombe Hp123jq
United Kingdom
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Mobile Phone07514524380
Home Phone01494512848
Applicant Email AddressEmail hidden; Javascript is required.
Availability for Work
Availability to start work15/04/2024
Availability over the next 12 monthsOngoing
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 Number5109325
Child Protection / Venerable Adults level 2/316/09/2022
Have you been appraised within the last 12 months?Yes
Name of AppraiserJennifer Galway
Position and Grade of AppraiserGrade 6 manager
Date of last appraisal06/12/2023
Appraisal Statement - Select if you agree with the following statements
  • 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?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?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)Royal derby hospital
Position Held (Employer 1)Pharmacy technician
Location (Employer 1)Hospital
Tel Number (Employer 1)01332623700
Date From (Employer 1)18/04/2023
Date To (Employer 1)19/01/2024
Employer name (2)Wells road centre
Position Held (Employer 2)Pharmacy technician
Location (Employer 2)Dispensary
Tel Number (Employer 2)01159691300
Date From (Employer 2)20/09/2022
Date To (Employer 2)24/03/2023
Employer name (3)Medicine drop pharmacy
Position Held (Employer 3)Dispenser- pharmacy technician
Location (Employer 3)Dispensary
Tel Number (Employer 3)01332869229
Date From (Employer 3)18/11/2016
Date To (Employer 3)01/07/2022
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 RefereeJennifer Galway
Email of First RefereeEmail hidden; Javascript is required.
Address of First RefereeRoyal derby hospital
Uttoxeter road
Derby De22 3ne
United Kingdom
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Phone of First Referee01332340131
Known Capacity of First RefereeN
Name of Second RefereeTejash Naik
Email of Second RefereeEmail hidden; Javascript is required.
Address of Second RefereeWells
Road
Mapperly, Nottingham Ng3 3aa
United Kingdom
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Phone of Second Referee011509691300
Known Capacity of Second RefereeN
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
Applicants NameHafifa Sajid
Applicant's Signature
For Office Purposes OnlyTHE F2F OFFICER MUST COMPLETE THE BELOW BEFORE LEAVING THE MEETING.