| Consent |  I confirm |
|---|---|
| Please select below if you do/do not agree for your personal data to be made available to any 3rd party without direct supervision from a member of staff from TLA or myself being present. |
|
| I confirm that I give my permission to The Locum Agency to share my data with Total Assist Recruitment | I do |
| Department | TLA |
| Name | Julius Siupan |
| Professional Registration Number | RA57022 |
| Date of Birth | 01/07/1975 |
| Signature (Locum) | |
| Locum signature Date | 23/08/2024 |
| Signature (TLA) | |
| TLA signature Date | 23/08/2024 |
