Application Form

"*" indicates required fields

2PERSONAL DETAILS

3PROFESSIONAL REGISTRATION DETAILS

4QUALIFICATIONS

7REFERENCES

9DECLARATION

PERSONAL DETAILS

Title

Your Name*

Have you ever been known by another name?

Date of Birth*

Gender*

Male

Female

Address*

House name or no: Street: City County: Postcode Country

Date of Residence*

Tel Work:

Tel Home/Mobile:*

Your Email Address*

Hidden

What job/s are you applying for?*

EMERGENCY CONTACT / NEXT OF KIN

Next of Kin Name*

Next of Kin Email*

Relationship to you:*

Tel / Mobile:*

NATIONALITY AND ELIGIBILITY TO WORK

Do you hold a British/EU Passport?*

Yes

Nationality*

Do you hold a visa?*

Yes

Please provide right to work share code if applicable

Share code:

National Insurance Number

Passport Number:

Expiry Number:

PROFESSIONAL REGISTRATION DETAILS

Are you registered with any Professional Body?*

Yes

Professional Body Membership*

NMC

GMC

Other

Please select all applicable

Other Professional Body

Registration Number:*

Expiry Date:*

Revalidation Date:*

Band/Grade:*

Speciality*

PROFESSIONAL APPRAISAL

(List your most recent appraisal)

Date of Appraisal:*

Location of Appraisal:*

Completed by*

I can confirm that I have read this document fully and that all the information provided to Urgent Response Healthcare is correct and to the best of my knowledge. I give consent to contact referees regarding the information I have provided unless specified otherwise. I will inform Urgent Response Healthcare should anything change, that might affect my position and I understand the information given on this form will be processed by computer and used for registration purposes, under the Data Protection Act 1998.

1. I understand that if I am at any stage charged or cautioned after signing this declaration, I must inform Urgent Response Healthcare.

2. I acknowledge that I have been given a copy of the terms of engagement of service issued by Urgent Response Healthcare, which is mine to keep, and furthermore that I have read those terms of engagement and agree to abide by them.

3. 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 Occupational Health Form.

4. I acknowledge and confirm that Urgent Response Healthcare is authorised to apply for and obtain a Disclosure and Barring Service (DBS) check and references from any previous employers and educational establishments.

5. I declare that the information given herein is true and complete and is not presented in a way intended to mislead. I agree that if I have given false or misleading information or omit to give relevant information now or in the future that Urgent Response Healthcare may cease to offer me further agency placements without notice, as well as claim for recovery of any payments I have received, together with a claim for loss of profit to Urgent Response Healthcare.

6. I agree that the maximum weekly working time specified in Regulation 4(1) and (2) of the Working Time Regulations 1998 shall not apply to working with Urgent Response Healthcare unless specified above.

7. I acknowledge that my personal details will be stored and handled correctly by Urgent Response Healthcare in accordance with the Data Protection Act 1998, however, I agree that they may be made available for audit/review by relevant third parties. (This is relevant for all information including all documents - DBS, Occupational Health, References, Right to Work).

8. I give consent for Urgent Response Healthcare to disclose my documentation including my payslips and timesheets to be shared with the NHS national framework, or any person, firm or organisation duly authorised on the authority’s behalf for audit purposes only.

9. I understand that if I am on a student visa I can only work for 20 hours per week during term time. I understand that I have a responsibility to monitor this. In addition, if my position as a student change, I must inform Urgent Response Healthcare.

10. I understand that if I am on a Tier 2 Sponsorship Visa, I can only work for a maximum of 20 hours per week at the same professional level as my sponsorship. I understand that I have a responsibility to monitor this. In addition, if my position with my sponsored company changes, I must inform Urgent Response Healthcare.

11. I acknowledge that if any of my details stated on this Application Form change, or my circumstances change, which may affect my ability to work for Urgent Response Healthcare, I must inform Urgent Response Healthcare immediately.

12. I confirm that I am not currently under investigation, or currently suspended, by my professional regulatory body or being investigated by my current or previous employer. I will inform Urgent Response Healthcare if I am under investigation or suspended by my professional regulatory body or employer at any point while working for Urgent Response Healthcare.

13. I confirm that when asked about my working history (primarily, but not exclusively, for the purpose of the Agency Workers Regulations) I will provide accurate information.

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