Employment Application Form

Personal Details

Title

Forenames

Surname

Other Names Used Since BirthIf so please provide documentary evidence to support i.e. Marriage Certificate ETC

Email Address

Phone

Street Address

Apartment, suite, etc

City

State/Province

Post Code

Country

National Insurance Number

Tax Self-Assessment Number

Emergency Contact

Name

Relationship

Email Address

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Identification Checks

Upload Photo IdentificationPlease provide photo identification (e.g. Passport, Driving Licence, British Residence Permit)

No file chosen

Upload Proof of Address2 x copies of proof of address (e.g. household bills showing current address, dated within the last 3 months)

Do you hold a UK Driving Licence?YesNo

Upload your Driving LicenceIf you hold a UK Driving Licence please upload a copy of the front & back.

Regulatory Authority

Name of your Regulatory Authority

Membership Number

Please confirm whether you are currently under investigation by your Regulatory Authority or any other organisation?YesNo

Have you ever been investigated by the GMC/GDC/NMC or any other organization?*Please be advised that this is the responsibility of the applicant to inform Triple 3 Healthcare Group Limited of any change or restrictions to their registered professional body status immediately upon awareness or notification of any kind of investigation by either an NHS body, or other wider public sector body, or your relevant Professional and Regulatory Body. For a detailed list of the regulatory authorities included within the definition of ‘Regulatory Authority’ please see our terms and conditions of engagement for doctors, nursing staff and allied healthcare professionals.YesNo

Appraisal InformationUnder the conditions of the NHS ‘Framework Agreement for the supply of Medical Locums’ all Doctors/Nurses/Allied Health Professionals 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/confirmation)

Mentor's/Appraiser's Name

Appraisers GMC/NMC No.

Job Title

Trust Name

Email Address

Phone

Date of Last Appraisal

Date of next Appraisal

Date of your Next Revalidation/Confirmation:

PROFESSIONAL INDEMNITY INSURANCE

Name of Insurance Company

Policy No.

Upload a Copy of the Insurance Policy

No file chosen

EDUCATION AND PROFESSIONAL TRAININGList all professional qualification held and training courses undertaken pertaining to work within an Acute Hospital Trust, Mental Health Trust or Clinical Commissioning Group. 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.

Qualification / Course

Institution / Venue

Date Started

Date Completed

Upload supporting evidence of your qualificationUpload certificates

No file chosen

Qualification / Course

Institution / Venue

Date Started

Date Completed

Upload supporting evidence of your qualificationUpload certificates

No file chosen

Qualification / Course

Institution / Venue

Date Started

Date Completed

Upload supporting evidence of your qualificationUpload certificates

No file chosen

Qualification / Course

Institution / Venue

Date Started

Date Completed

Upload supporting evidence of your qualificationUpload certificates

No file chosen

ADDRESS HISTORYLast 5 years address history required

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

From

ADDRESS HISTORYLast 5 years address history required

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

From

ADDRESS HISTORYLast 5 years address history required

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

From

ADDRESS HISTORYLast 5 years address history required

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

From

ADDRESS HISTORYLast 5 years address history required

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

From

EMPLOYMENT HISTORYPlease list your full employment history, starting with your most recent/ current employer. Please explain any gaps in your employment in the space provided. Please continue on a separate sheet if necessary.

Employer Name

Position Held

Email Address

Phone

From

Explanation of Gaps in Employment History

Employer Name

Position Held

Email Address

Phone

From

Explanation of Gaps in Employment History

Employer Name

Position Held

Email Address

Phone

From

Explanation of Gaps in Employment History

Employer Name

Position Held

Email Address

Phone

From

Explanation of Gaps in Employment History

WORK REQUIREMENTS & AVAILABILITY

Date you are available from

Date you are available to

Date you are not available from

Date you are not available to

Please provide any further information regarding your availability?

Please provide us with your nearest underground /railway station and bus route

Do you have your own transport?YesNo

PROFESSIONAL REFEREE 1Please supply two recent professional referees from your current/ last substantive post. (ideally to cover the last 3 years) If this is not possible, please contact us to discuss suitable alternatives.

Referee Name

Capacity in which Known

Email Address

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

PROFESSIONAL REFEREE 2Please supply two recent professional referees from your current/ last substantive post. (ideally to cover the last 3 years) If this is not possible, please contact us to discuss suitable alternatives.

Referee Name

Capacity in which Known

Email Address

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

PROFESSIONAL REFEREE 3Please supply two recent professional referees from your current/ last substantive post. (ideally to cover the last 3 years) If this is not possible, please contact us to discuss suitable alternatives.

Referee Name

Capacity in which Known

Email Address

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

BANK AND BUILDING SOCIETY DETAILS

Bank/Building Society Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Account Holders Name

Sort Code

DECLARATIONSI, the undersigned hereby confirm and agree that the information giving in this application form is true and correct. I consent to my personal data and CV being forwarded to clients or that of a third party for auditing purposes. I hereby consent for Triple 3 Healthcare Group Limited to verify the information relating to this application in order to comply with governed recruitment procedures and to satisfy the interests of patient safety. Furthermore, I consent for information held by Triple 3 Healthcare Group Limited about me to be viewed by the authority or any framework provider at their request and for the fulfilment of all regulatory requirements as necessary.

Termination of EmploymentI understand that should any information come to light following any employment that I undertake, which shows that any information or medical information disclosed by me in this application was found to be misleading of false, Triple 3 Healthcare Group Limited has the right to terminate my contract with immediate effect

Working Time RegulationsThe Working Time Regulations 1998 ("The Regulations") require the Company to limit your average weekly working time to 48 hours unless you agree with the Company that the limit shall not apply to you. The Company wishes to have an agreement with you. It proposes an agreement (which will apply until terminated by notice) on the basis that: • The 48 hour limit on average weekly time will not apply to you • You may terminate the agreement (so that the 48 hour time limit would apply to you) by giving the Company 4 weeks written notice Under the Regulations, the Company must keep records relating to your working time. This is the case whether or not you reach an agreement with the Company about waiving working time limits.

CheckboxDeclarationI wish to work more than 48 hours per week.I do not wish to work more than 48 hours per week.

Mandatory Training & AppraisalI understand that it is my responsibility to undergo an annual appraisal and attend mandatory training in the following disciplines annually: Moving and handling, health and safety (1974 & 1999), fire safety, Clostridium Difficile & MRSA COSHH, RIDDOR, risk incident reporting, complaints handling, lone work training, data protection, infection control & prevention, handling violence and aggression, conflict resolution, the Caldicott protocols, handling patient information, safeguarding children and adults, equality and diversity, dementia training, fraud awareness, level 2 basic life support, control and restraint / breakaway, intention to practice (midwives only), newborn CPR / CTG (midwives only), Basic Food Hygiene (nursing only). Other mandatory training as required by the authorities.

HandbookI declare that I have received, read and understood the Triple 3 Healthcare Group Limited Induction Handbook and that I am already trained to NHS standards in all areas as described. Should I feel I require training in any area I will contact Triple 3 Healthcare Group Limited immediately. I acknowledge that I have been presented with a copy of the terms and conditions enclosed within the induction handbook and confirm I will abide by these terms and conditions.

Data Protection & GDPRThe information that you provide on this form and on any CV will be used by Triple 3 Healthcare Group Limited to identify suitable locum opportunities. In providing this service to you, you consent to your personal data being included on a computerised database and consent to us transferring your personal details to our clients and other third parties as required including Framework Assurance Auditors. At all times, your personal data will be controlled in accordance with our GDPR obligations. A copy of our Privacy Statement is available

IR35 & Criminal Finance Act obligations.In accordance with IR35 & Criminal Finance Act obligations, we are required to ensure that appropriate payroll deductions are being made on your behalf. As such, you sign to agree that assurance checks can be made in relation to your chosen payment method which include but are not limited to: • Provision of Umbrella Company copy pay slip both from you as an individual and also the Umbrella Company you have chosen to operate through. • Any and all reasonable checks required by Triple 3 Healthcare Group Limited to satisfy its legal and regulatory obligations under current and future IR35 & Criminal Finance Act legislation. You sign to agree that you will only engage the services of a third-party Umbrella Company provider who satisfies the regulatory HMRC conditions of use.

Criminal Records CheckYou are required to complete an enhanced DBS Disclosure. Triple 3 Healthcare Group Limited will send to you via email an electronic link in order that you can complete and return this to us promptly. If registered with the DBS Update Service, I provide Triple 3 Healthcare Group Limited with authority & consent to apply for a DBS update check. I sign to declare that to the best of my knowledge, I am unaware of any spent or unspent previous convictions subject to The Rehabilitation of Offenders Act 1974 (exceptions) order 1975 (amended) (England and Wales) order 2013, S.l. 2013/1198.

Have you undertaken a Disclosure and Barring Check (DBS) within the past 12 monthsYesNo

Date you were last checked?

Have you been convicted of a criminal offence, been bound over or cautioned or are you currently the subject of any police investigations? Please tick accordingly.YesNo

If yes, please provide details below including date, offence and authority / country which dealt the offence

Nature of incident

Date of Incident

Outcome of incidentFailure to declare an incident or occurrence as described may require us to exclude you from our register or terminate an assignment if the incident or occurrence is not declared but later comes to light.

Rehabilitation of Offenders Act 1974 (exceptions) Order 1975You are required to disclose details of all criminal offences, suspensions, cautions and, convictions including where you have been party to a criminal investigation or prosecution without formal outcome and from which any convictions are spent or remain unspent. This information may be shared with third parties and in providing the disclosure you accept that the information may be disclosed as required under law or any other relevant legislation. The information given will be treated in the strictest of confidence and only taken into account where, in the reasonable opinion of Triple 3 Healthcare Group Limited the offence is relevant to the post to which you are applying. Include all relevant convictions other than minor offences such as parking fines and speeding tickets.

Changes to your CircumstancesIt is important that you tell us as soon as reasonably possible if your circumstances change or if any of the information shown in your application has changed during your contract / period of work with Triple 3 Healthcare Group Limited.

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