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

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.

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.

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