Application Form (Doctors)

University / College

Qualification

Date Taken

Qualified

Please give details of 5 years of your employment history. Please start with the most recent one. *

Name of Employer

Start Date

End Date

Position

Training
Do you hold Training Certificates for any of the following? (Please tick) *

Manual Handling Health & Safety Basic Life Support Adult Life Support MOET Prevention and Infection Control Handling Violence & Aggression Mental Health Act Paediatric Adult Life Support

References

Please provide details of at least two professional references. One reference must be from your most recent employer and another one from your previous employer
Name *
Position *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Tel No *
Please enter a valid phone number.
Fax No
Email *
example@example.com
Name *
Position *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Tel No *
Please enter a valid phone number.
Fax No
Email *
example@example.com
Name
Position
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Tel No
Please enter a valid phone number.
Fax No
Email
example@example.com
I hereby give consent to Flamelily Healthcare to contact the professional referees that I have listed above or mentioned in the CV, to obtain professional reference for registration and clearance for locum work with NHS.
Signed *

Clear
Date *

Month Day Year
Date

Availability of Work
What is your availability of work? *

Temporary Permanent Both
Available to start work from: *

Month Day Year
Date
Do you hold a valid UK Driving License? *

Yes No
How far are you prepared to travel to work? (Please tick) *

I want something local Ok to travel 15 – 50 miles I am willing to relocate

Health
Have you ever been screened for below? (Please tick and provide proof)

Hep B TB Measles, Mumps & Rubella Varicella Hep B Surface Antigen HIV Hep C
Proof

Cancel of
I give my consent to The Flamelily Healthcare to obtain my personal occupational health records and/or similar data from third parties such as NHS trusts or GP doctors for registration and clearance for locum work with the NHS.
Signed *

Clear
Date *

Month Day Year
Date

Professional Conduct
Have you ever been the subject of a Disciplinary Investigation or Professional Misconduct Proceeding or Disciplinary Proceedings by the previous employer or have such pending against you either in the UK or Abroad? *

Yes No
If Yes, please give details: -

Rehabilitation of Offenders ACT

Convictions will not necessarily be a bar to obtaining a post. However, because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 42 of the Rehabilitation of Offenders Act 1974. Applicants must declare information about convictions, cautions, reprimands and final warnings, for which other purposes are “spent” under the provisions of the Act.
Have you ever been convicted, cautioned, reprimanded or given a final warning for a criminal offense? (Please Tick) *

Yes No
Are you waiting to hear about any pending prosecutions? (Please Tick) *

Yes No
Are you aware of any police enquiries undertaken following allegations made against you, which may have a bearing on your stability for this post? (Please Tick) *

Yes No

Emergency Contact Details

Please provide details of the person you would like to be contacted in the event of an emergency
First Name *
Last Name *
Relationship *
Postal Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Number
Mobile Number *
Please enter a valid phone number.
Email Address
example@example.com

Work Time Directives
In accordance with the implementation of working time regulations, The Flamelily Healthcare recommend that working time should not exceed 48 hours per week (Average over a period of 17 weeks). However, should you wish to opt out of the Work Time Directives, please tick below: -

Yes, I wish to opt out of Work Time Directives

Data Protection
The information that you provide on this form and on any CV given will be used by The Flame Lily Healthcare Ltd to provide you work finding services. In the case of working with vulnerable persons and where professional qualifications / authorisations are required by law, we will offer to provide details of both your references and qualifications to the clients. In providing this service to you, you consent to your personal data being included on a computerized database and consent to us transferring your personal details to our clients. We may check the information collected, with third parties or with other information held by us. We may also use or pass to certain third parties information to prevent or detect crime, to protect public funds, or in other way permitted or required by law. Please tick below to agree on above data protections statement. *

Yes, I agree.

Declaration
I, hereby confirm that the information given is true and correct. I give consent for my personal data and CV being forwarded to clients. I give consent to The Flamelily healthcare to share my references with potential employers. I understand that any personal data held by The Flamelily Healthcare is liable to be inspected by NHS and other third party organisations as a part of audit procedures and provide my permission for The Flamelily Healthcare to disclose all or any element of my personal data for this purpose. I will notify the Flamelily Healthcare of any changes to my professional conduct record, fitness to practice and criminal convictions status. By signing this declaration, I agree to everything herein. If, during a temporary assignment, the Client wishes to employ me direct, I acknowledge that The Flame Lily Healthcare will be entitled either to charge the client an introduction/transfer fee, or to agree on an extension of the hiring period with the Client (after which I may be employed by the Client without further charge being applicable to the Client). *

Clear
Date *

Month Day Year
Date
Type a question *
Should be Empty:

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