Freelance Phlebotomist Application Form

Freelance Phlebotomist Application Form
Identification
Full Name*

First NameMiddle NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email Address*
example@example.com
Please upload your most recent CV*

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Please provide a short explanation for any gaps in employment
Upload an image of your Passport/ Birth Certificate*

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Name of current employer:

First NameLast Name
Upload an image of your Driving License

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Qualifications and experience
YesNo
NurseParamedicDoctorPharmacistNo RegistrationOther
PIN / Registration Number:
Do you have any convictions and/or cautions that are not protected?

This means any that they're not eligible for filtering, as outlined in the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended).

It also includes all convictions or Summary Hearings issued under military law while serving in the Armed Forces in the UK or any other country, where the equivalent offence in England and Wales is not protected.

Fitness to practise investigations and proceedings
You'll need to give us details about any fitness to practise investigations and proceedings by a regulatory or licensing body you've had.

This includes any:
- warnings
- limitations, suspension or any other restrictions
- conditions or sanctions placed on your registration
- time you were removed from the register
YesNo
YesNo
Details of above if yes:
If you have voluntarily given up your registration, please give a date of when and reason:
Upload your Phlebotomy Evidence Log (Word/Excel/PDF/Photo evidence)

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Adult Safeguarding Level 2

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Infection Control

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Health & Safety

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BLS

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GDPR

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Tell us a bit more about your patient facing phlebotomy experience:
Criminal Records Bureau & Disclosure and Barring Service

ECG require a DBS/ PVG check for all Clinical Staffing Freelancers and Trainer Freelancers. If you do not have a valid DBS/ PVG we will complete a DBS/ PVG application, and the cost will be deducted from first invoice or invoiced within three months if no shifts are agreed.
YesNo
If Yes DBS/ PVG Number:
If Yes DBS/ PVG Issue date
YesNo
Date of cautions or convictions?
Nature of offence or cautions?
Upload an image of your DBS/ PVG

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Additional Questions
YesNo
What is your availability per month?
How far are you willing to travel?
References
Please give the names and contact details of 2 people who we can ask to give you a reference. The first referee you provide needs to be from your current/ most recent employer.

You must not give the names of friends, relatives, or colleagues that are/were not senior to you as referees. All references will be verified.
'Candidate' I consent to ECG contacting references:*
Reference 1 Name (Should be current or most recent employer):*

First NameLast Name
Name of organisation:*
Position:*
Date of employment:*

MonthDayYear
Date
To end date of employment:

MonthDayYear
Date
Email*
Phone Number*

Area CodePhone Number
Reference 2 Name *

First NameLast Name
Name of organisation:*
Position:*
Date of employment:*

MonthDayYear
Date
To end date of employment:

MonthDayYear
Date
Email*
Phone Number*

Area CodePhone Number
Please note that ECG Healthcare Group is a Disability Confident Employer and is committed to promoting and sustaining Equality and Diversity within the workplace.
Should be Empty:

Freelance Phlebotomist Application Form

Criminal Records Bureau & Disclosure and Barring Service

Additional Questions

References