Candidate Registration Form

Personal Details:
Full Name*

First NameLast Name
Title
Date of Birth

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Phone Number
E-mail

Nationality and Eligibility to work in the UK:
Nationality
Passport No:
National Insurance No:
Do you require a visa to work in the UK?

YesNo
Visa No:
If you answered "Yes" Please give details below.
Is there a restriction on the length of time you can work in the UK?

YesNo

Professional Qualifications and Training

List all professional qualifications held and training courses undertaken pertaining to work within an Acute Hospital Trust, Mental Health Trust or CCG. In particular, please confirm details of your VTS. Professional qualifications and training will be verified. Continue on a separate sheet if necessary. Please provide photocopies of all certificates. (For convenience, and where appropriate, please state: Please see CV)
GMC/ NMC NUMBER
Indemnity Provider

Professional Referees
First NameLast Name
Job Title
Address

Street Address

Street Address Line 2

CityCounty

Postal
Phone Number

Area CodePhone Number
Email
example@example.com
First NameLast Name
Job Title
Address

Street Address

Street Address Line 2

CityCounty

Postal
Phone Number

Area CodePhone Number
Email
example@example.com

Declaration of Criminal Record & Professional Conduct

Applicants for locum medical positions are exempt from the Rehabilitation of offenders Act 1974.
Have you ever been convicted of a criminal offence, been bound over or cautioned or are you currently the subject of any police investigations?

YesNo
Do you have an Enhanced Criminal Record Bureau (CRB) Disclosure Certificate?Please circle as appropriate.

YesNo
Do you have a valid DBS Certificate? Please circle as appropriate.

YesNo
If you answered "Yes" Please give details below.
If you have ever been the subject of a professional misconduct proceeding or suspension from an employer, or have such procedures pending against you either in the UK or abroad, you are legally obliged to provide details in the space below.
Appraisal

Under the conditions of the NHS ‘Framework Agreement for the supply of Medical Locums’ all Doctors are responsible for ensuring that they are appraised on a regular basis, and it is our responsibility to hold on file confirmation of appraisal. (Please include a copy of your post-appraisal summary letter).
Mentors/Appraisers

First NameLast Name
Job Title
Phone Number

Area CodePhone Number
Date of Last Appraisal

DayMonthYear
Date

Declarations
I acknowledge that I have been given a copy of the terms and conditions of service issued by Reachout Medical for both PAYE locums and locums whom work via a limited company, which are mine to keep, and furthermore that I have read those terms and conditions and agree to abide by them.

I acknowledge that my personal details will be stored and handles correctly by Reachout Medical in accordance with the Data Protection Act 1988. I acknowledge that my personal details may be made available for audit by the relevant Statutory and Government organisation.

I accept that in the event of my being engaged with Reachout Medical, I will be liable to disciplinary proceedings if it is subsequently shown that medical information was not disclosed to Reachout Medical, or has been misleading or false.

I declare that I have been given a copy of the Locum Handbook issued by Reachout Medical, which is mine to keep and I confirm that it has been read, fully understood and that I shall comply with its requirements at all times.
I declare that all the foregoing statements are correct and true to the best of my knowledge and belief.
Please print full name

First NameLast Name
Signature*

Clear
Date

DayMonthYear
Date
Working Time Directive: WTR 48 Hour Working Week OPT-Out

The Working Time Directive requires that worker’s average working time must not exceed 48 hours per week unless the worker agrees in writing to exceed the limit. Please sign the declaration below in order that we may lawfully employ you if your hours exceed 48. Please note that by signing this Opt-Out you are not committing to a working week of more than 48 hours, but rather allowing yourself to be offered assignments that could take you over this threshold.
Name

First NameLast Name
Siganture*

Clear

Personal Details:

Nationality and Eligibility to work in the UK:

Professional Qualifications and Training

Professional Referees

Declaration of Criminal Record & Professional Conduct

Appraisal

Declarations

I declare that all the foregoing statements are correct and true to the best of my knowledge and belief.

Working Time Directive: WTR 48 Hour Working Week OPT-Out

CHECK LIST: DOCUMENTS COMPLETED & ENCLOSED