| 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 | Qutubul Ahsan |
| Professional Registration Number | 5005854 |
| Date of Birth | 31/10/1963 |
| Signature (Locum) | |
| Locum signature Date | 09/06/2024 |
| Signature (TLA) |
