APPLICATION FORM

PERSONAL INFORMATION
Please note: Your name should be in full, as appearing on the NMC register and passport
Title: First Name: Surname:
DOB: Home Tel No: Mobile No:
Address:
Post Code: City:
Email Address:
National Insurance Number:
NEXT OF KIN

Full Name: Relationship:

Address:

Telephone No:
PROFESSIONAL DETAILS

Job Title:
Professional registration Body (NMC/HPC): Professional Registration Number:
Date of last appraisal: Date of next appraisal:
RIGHT TO WORK IN THE UK

I Confirm I am eligible to work In the UK on the following basis:

Are you an EEA National/ Citizen? YES NO (please answer next question)

What type of Visa/ Documentation do you hold to support your eligibility to work in the UK?

FITNESS TO PRACTICE

Have you been or are you currently subject to any fitness to practice proceedings by an appropriate licensing or
regulatory body in the UK or any other country?
YES NO

If Yes, please provide information on a separate sheet detailing the nature of the proceedings undertaken, or contemplated,
including approximate date of proceedings, country where proceedings were undertaken and the name and address of the
licensing or regulatory body concerned.

EMPLOYMENT/EDUCATION HISTORY

Please submit your full Employment/Education history via a copy of your current CV.
• Please supply details of your work history from school to date
• Please explain any gaps of 2 weeks or more

V082021 Brit Locums Ltd

108 Cranbrook, Ilford IG1 4LZ LONDON
[T] 0207 265 9382 [E] admin@britlocums.co.uk
REHABILITATION OF OFFENDERS ACT

Have you been convicted of a criminal offence, been bound over or cautioned or are you currently the subject of any
police investigations, which might lead to a conviction, an order binding you over or a caution in the UK or any other
country?

Yes No

If yes, please provide outline on a separate sheet the criminal offence, order binding you over, a caution, including approximate
date, the offence and the authority and country which dealt with the offence.
DISCLOSURE AND BARRING SERVICE

All public and private organizations request that an Enhanced Disclosure be obtained for all healthcare personnel acquired from
the Disclosure and Barring Service or Disclosure Scotland through Brit Locums.

Do you have an Enhanced Disclosure and Barring Service certificate: Yes No

Certificate Number: Issue Date:
Update service: Yes No

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.

Have you ever been convicted by the courts, cautioned, reprimanded, or given a warning by the police in the UK or in any other
country? Yes No

re you aware of any police enquiries undertaken following allegations made against you, which may affect your suitability for this role?
Yes No

Are you aware of any pending investigations by the police in which you are involved? Yes No

If you have answered yes to any of the above questions please provide full detailed personal statement with this application.

PROFESSIONAL REFERENCES

Please provide names and contact details of professional referees from your most recent employment, which must
cover the last 5 years of employment/education. Referees must be working in senior position to yourself.
REFERENCE 1
Name: Position:
Email Address: Telephone number:
Organization address:
Relationship: Dates of Employment
REFERENCE 1
Name: Position:
Email Address: Telephone number:
Organization address:
Relationship: Dates of Employment

V082021 Brit Locums Ltd

108 Cranbrook, Ilford IG1 4LZ LONDON
[T] 0207 265 9382 [E] admin@britlocums.co.uk
GDPR DECLARATION

In accordance with the new general data protection regulations (GDPR) we are asking you to sign this to provide consent for Brit
Locums to collect and retain your information on our system.
Agreement to use my data
I hereby freely give my employer Brit Locums consent to use and process my personal data relating to my employment.
In giving my consent:
 I understand that I can ask to see this data to check its accuracy at any time via a subject access request.
 I understand that I can ask for a copy of the personal data held about me at any time, and that this request is free of
charge
 I understand that I can request that data that is no longer required to be held can be removed from my file
and destroyed.
 I understand that if I leave my employment, all physical and electronic records will be retained for a period of 6 years
after my last contact with Brit Locums, or if longer this is stated in the Privacy Notice
 I understand that you are the Data Controller for my employment, and I can contact you directly if I have any questions or
concerns about my data.
I understand that if I am dissatisfied with how you use my data, I can make a complaint to the government body in charge
(Information Commissioner’s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF or online at www.ICO.org.uk)

Name: Signature: Date:

V082021 Brit Locums Ltd

108 Cranbrook, Ilford IG1 4LZ LONDON
[T] 0207 265 9382 [E] admin@britlocums.co.uk
DECLARATIONS

Working Time Directive

The Working Time Regulations 1998 require Brit Locums to limit your average weekly working time to 48 hours unless
you agree with Brit Locums that the limit shall not apply to you:
Yes, I agree to limit my working week to no more than 48 hours
No, I disagree to limit my working week to no more than 48 hours

I can confirm that I have read this document fully and that all the information provided to Brit Locums is correct and to
the best of my knowledge and belief.
I give consent to contact referees regarding the information I have provided unless specified otherwise.
I will inform Brit Locums 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 Brit Locums
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 Brit Locums is authorized 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 Brit Locums 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 Brit Locums.
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 Brit Locums unless specified above.
7. I acknowledge that my personal details will be stored and handled correctly by Brit Locums 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).
8. 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 changes, I must inform Brit Locums.
9. 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 Brit Locums.
10. 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 Brit Locums, I must inform Brit Locums immediately.
11. 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 Brit Locums if I am under investigation or suspended by my professional
regulatory body or employer at any point while working for Brit Locums.
12. 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.
13. I acknowledge that should I reach the 12-week Qualifying Period under the Agency Workers Regulations, I may be asked for,
and will provide, further documentation as evidence of qualifying weeks, if Brit Locums deem it necessary.
14. I acknowledge that I have received and read through the Brit Locums Limited candidate handbook. I will abide and comply
with all procedures stated

Name:

Signature Date:

Data Protection Statement: All of the information collected in this form is necessary and relevant to the performance of the job
applied for. We will use the information provided by you on this form, by the referees you have noted, and the educational
institutions with whom we may undertake to verify your qualifications with, for recruitment purposes only. The Company will treat
all personal information with the utmost confidentiality and in line with current data protection legislation.

V082021 Brit Locums Ltd

108 Cranbrook, Ilford IG1 4LZ LONDON
[T] 0207 265 9382 [E] admin@britlocums.co.uk