Application form – Locum Tenens

Personal Details

Title

Mr
Mrs
Miss
Ms
Dr

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First Name *

Date of birth

Last Name *

Gender

Male
Female
Other

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Nationality *

NI Number *

Address *

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Phone

Mobile *

E-mail address *

Next of KIN

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Full name *

Address *

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Relationship *

Phone *

Mobile *

References

Please provide names and addresses of two people with either medical or nursing qualifications or holding positions within the field of care, who are able to provide information on your experience and suitability for the post applied for. References for qualified nurses must be professionals. Relatives are not acceptable.

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Reference 1

Full name *

Position *

Relationship *

Address *

Phone

May we approach this reference prior to the interview? *

Reference 2

Full name *

Position *

Relationship *

Address *

Phone *

May we approach this reference prior to the interview? *

Education and Training

Secondary School, College, University attended. Please leave blank where Not Applicable.

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Name of institution

Location *

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Qualifications Obtained

Dates

Professional Qualification

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Nurse Training School *

Qualification *

Year obtained *

Address *

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NMC Registration *

GMC Registration *

Pin Number

Registration Number

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Expiry Date

Union Membership

S/NVQ or other course

Employment History

Please give details of the past five years continuous work history. Begin with your most recent employer.

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Employer's Name *

Address *

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Position Held *

Date From *

Date To *

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Responsibilities *

Supporting Statements *

Declaration of Health

Please answer the following questions by ticking the appropriate Yes / No option.

Have you ever in your life, including childhood had any of the following?

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Cardiac or vascular disease? *

Eye disease or Injury? *

Epilepsy? *

Diabetes? *

Hepatitis? *

Back pain or Injury? *

Illness / Operation? *

Registered disabled? *

Are you medically fit? *

Do you Smoke or Drink? *

Tuberculosis? *

Asthma? *

Chicken Pox? *

Hearing Loss? *

Physical Deformities? *

Any serious health condition? *

Mental illness? *

Infectious disease? *

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GP´s name *

Address *

Phone *

Rehabilitation of Offenders Act 1974

The Rehabilitation of the offenders Act [1974][exemptions Order 1975] the provisions of sction [4.2] of the Rehabilitaion of Offenders Act 1974 do not apply to any employment which is concerned with the provisions of healthcare services to vulnerable adults and children or have access to thier records during the normal course of his/her duty. Your answer to the question below should include any spent convictions.

Have you ever been convicted of a criminal offence? *

If yes, please give details below. The information you provide will be held securely and treated as being in confidence under terms of the DATA PROTECTION ACT 1984

Conviction details

CRB

The post that you have requested is subject to checks being made through the Disclosure and Barring Service (DBS), as it involves either working with children or vulnerable adults.

Do you agree such checks may be made concerning you if required? *

Declaration

Acceptance *

I have read and understood the Declaration

Email *

Send an application

Personal Details

Next of KIN

References

Reference 1

Reference 2

Education and Training

Professional Qualification

Employment History

Declaration of Health

Rehabilitation of Offenders Act 1974

CRB

Declaration

Tell Us What You Need
We'll Find It for You!

Find Your Perfect Fit in Primary Care

Send an application

Personal Details

Next of KIN

References

Reference 1

Reference 2

Education and Training

Professional Qualification

Employment History

Declaration of Health

Rehabilitation of Offenders Act 1974

CRB

Declaration

Tell Us What You Need We'll Find It for You!

Find Your Perfect Fit in Primary Care

Tell Us What You Need
We'll Find It for You!