Application Form (Doctors)
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*
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Personal Details
First Name
*
Title
*
Middle Name
DOB
*
-
Month
-
Day
Year
Date
Last Name
*
Marital Status
*
Married
Single
Any Previous Names
Male / Female
*
Male
Female
Current Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Home Number
*
Mobile Number
*
Please enter a valid phone number.
Preferred Method of Contact
*
Email Address
*
example@example.com
Permanent Address Same as Current Home Address?
Yes
Permanent Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
NI No
*
Job Title
*
Specialty
*
GMC Number
*
Revalidation Date
*
-
Month
-
Day
Year
Date
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Employment Requirements
Right to Work in UK
Nationality
*
Please Select
Afghan
Albanian
Algerian
Argentinian
Australian
Austrian
Bangladeshi
Belgian
Bolivian
Batswana
Brazilian
Bulgarian
Cambodian
Cameroonian
Canadian
Chilean
Chinese
Colombian
Costa Rican
Croatian
Cuban
Czech
Danish
Dominican
Ecuadorian
Egyptian
Salvadorian
English
Estonian
Ethiopian
Fijian
Finnish
French
German
Ghanaian
Greek
Guatemalan
Haitian
Honduran
Hungarian
Icelandic
Indian
Indonesian
Iranian
Iraqi
Irish
Israeli
Italian
Jamaican
Japanese
Jordanian
Kenyan
Kuwaiti
Lao
Latvian
Lebanese
Libyan
Lithuanian
Malagasy
Malaysian
Malian
Maltese
Mexican
Mongolian
Moroccan
Mozambican
Namibian
Nepalese
Dutch
New Zealand
Nicaraguan
Nigerian
Norwegian
Pakistani
Panamanian
Paraguayan
Peruvian
Philippine
Polish
Portuguese
Romanian
Russian
Saudi
Scottish
Senegalese
Serbian
Singaporean
Slovak
South African
Korean
Spanish
Sri Lankan
Sudanese
Swedish
Swiss
Syrian
Taiwanese
Tajikistani
Thai
Tongan
Tunisian
Turkish
Ukrainian
Emirati
British
American
Uruguayan
Venezuelan
Vietnamese
Welsh
Zambian
Zimbabwean
Country of Origin
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Please write your visa status
*
Do you require a Work Permit?
*
Yes
No
Visa Expiry Date (If Applicable)
-
Month
-
Day
Year
Date
Indemnity Insurance
Do you have a Personal Indemnity Insurance?
*
Yes
No
Company Name
Expiry Date
-
Month
-
Day
Year
Date
Do you belong to a Professional Body/Union?
*
Yes
No
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Qualification / Training
*
University / College
Qualification
Date Taken
Qualified
1
Yes
No
2
Yes
No
3
Yes
No
4
Yes
No
Please give details of any further qualification of training
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Employment History
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
1
2
3
4
5
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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
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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
*
Date
*
-
Month
-
Day
Year
Date
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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
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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
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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
*
Date
*
-
Month
-
Day
Year
Date
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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: -
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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
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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
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Payroll Details
Please tick below: -
Ltd. Co.
PAYE
Bank Name
Sort Code
Account Name
Account Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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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
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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.
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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).
*
Date
*
-
Month
-
Day
Year
Date
Type a question
*
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