Application Form

Please ensure that you complete all parts of the form and that you sign and date all declarations.

Please write clearly in block capitals.

Personal Information





YesNo

EU CitizenIndefinite Leave to RemainLimited Leave to RemainPlease state visa type and expiry dateOther, please specify
YesNo

YesNo

Appraisal/Revalidation


NMCGMC

Qualifications and Educational Information



Disclosure and Barring Service Checks


Please note that you will be subject to an Enhanced DBS Check. Because you are a health care worker you are not exempt from the Rehabilitation of Offenders Act 2010. This means that all convictions, cautions, reprimands and final warnings on your criminal record must be disclosed.

YesNo

YesNo

YesNo

References


You must provide the names and contact details for at least 2 professional references who can comment on your professional abilities.

Please note that one of these must be from your current or most recent post.

First Reference

Dates Employed

Second Reference

Dates Employed

Declarations


Please read the following declaration carefully. Make sure that you sign and date all declarations.

Working Time Directive

Regulation 4 of the Working Time Directive requires that a worker’s average time spent at work does not exceed 48 hours within 1 rolling week unless the worker hereby agrees to exceed this limit.
I hereby confirm that I am willing to opt out of the Working Time Directive. I understand that I can opt out of this agreement at any time providing I provide LHL with one week’s notice.


Please note should you choose to not opt out of the Working Time Directive that it is your responsibility to ensure that you do not work in excess of 48 hours per week.

  1. I declare that all the information provided by me to London Healthcare Locums and its subsidiaries is true and accurate and has not been presented in a way as to mislead or misinform. I agree that if I have given false or misleading information, if I have omitted or subsequently omit, information which may affect my ability to work in my chosen profession that LHL may cease to offer me further placements with immediate effect.
  2. I am not aware of any condition, medical or otherwise, which would affect or limit my performance or employment other than those already provided, including information provided in the Occupational Health Questionnaire.
  3. I hereby give permission for London Healthcare Locums and its subsidiaries to apply for and Enhanced DBS Check and I declare that I have not withheld any information which may be later disclosed by the DBS.
  4. I hereby give permission for London Healthcare Locums and its subsidiaries to obtain all my occupational health results and reports, qualifications and training information where necessary.
  5. I hereby give permission for London Healthcare Locums and its subsidiaries to contact the UKBA to perform a check on my Biometric Residence Permit.
  6. I acknowledge that my personal details will be stored in a secure environment, in compliance with IS27001. All information submitted to London Healthcare Locums will be used in strict accordance with the Data Protection Act (GDPR) (EU) 2016/679. I agree that all information provided to London Healthcare Locums can be made available for audit/review by relevant third parties. All third parties are required to:
    • Abide by the General Data Protection Regulation (GDPR) (EU) 2016/679.
    • Have a policy for the recruitment of ex-offenders and policy for secure storage, handling, ] use, retention, and disposal of disclosure certificates and Disclosure information.
  7. I hereby agree to immediately notify London Healthcare Locums and its subsidiaries of any changes to my circumstances or personal information including but not restricted to changes in my health; charges or investigations at work; changes to my DBS record or suspensions by my regulatory body.
  8. I hereby agree that I will act in a professional manner at all times when representing London Healthcare Locums and its subsidiaries and that I will fully co-operate with the instructions and duties allocated to me during each and every placement.
  9. I will immediately inform London Healthcare Locums and its subsidiaries if any complaint is made against me whilst on assignment for London Healthcare Locums or any other body.
  10. I acknowledge that it is my responsibility to ensure that my skills and knowledge are continuously updated and that I will always endeavor to carry out my duties and responsibilities to the best of my ability.
  11. I can confirm that I have been given a copy of the Terms and Conditions of Service issues by LHL, that I have read those Terms and agree to abide by them at all times.
  12. I agree to abide by the General Data Protection Act (GDPR) (EU) 2016/679 with regard to all information about London Healthcare Locums and its subsidiaries, clients, candidates, patients and any other third party who I interact with during my registration with London Healthcare Locums. I will not attempt to deliberately procure any information pertaining to London Healthcare Locums, clients, candidates, patients or any third parties that would be deemed to be outside of my job description. I will not discuss information either verbally or in writing and if I am unsure about how to treat any information I shall immediately contact London Healthcare Locums Senior Management for clarification.
  13. I can confirm that I have received the LHL handbook and that I will abide by the code of conduct thereby set out. This code incorporates the code of conduct as set out by the regulatory bodies the NMC, GMC and HCPC. I therefore agree that I will:
    • Respect the patient of client as an individual
    • Obtain consent before I give any treatment or care
    • Protect confidential information
    • Co-operate with others in my team
    • Maintain my professional knowledge and competence
    • Be trustworthys
    • Act to identify and minimise risk to patients and clients
    • Abide by the rules and regulations of the departments in which I work

I am happy for London Healthcare Locums to represent my details for any permanent recruitment in NHS trusts and Hospitals.

I understand that any personal data held by London Healthcare Locums is liable to be inspected by the CPP/HTE/CCS and/or any other authorized 3rd party.