Initial application form

Before we begin...
Registration with Medinet shouldn't take more than 8-10 days however there are some things we should let you know, before we start the process to ensure you have all of the information you need when we request it.

For information on how we use your personal information for the purposes of nprocessing your application, please see our privacy policy by clicking the link below.

View our privacy policy
Please confirm you provide your consent for us to process your data in line with the purposes described in our privacy policy*

I consent
As part of processing your application we may conduct a criminal records (DBS) check in line with the Rehabilitation of Offenders Act. Before proceeding with this application, please confirm you provide your consent, should it be required to undertake a DBS/Disclosure Scotland background check. We also ask you to confirm at this stage that you do not currently have any unspent convictions.*

I understand
Please confirm you have a valid and current right to work in the UK*

I confirm

Criminal convictions
Are you currently bound over, or have you ever been convicted of a criminal offence by a court / court martial in the UK or any other country?*

YesNo
Please give details*
Have you ever been named on the Protection of Children's list or have you ever been referred to the Independent Safeguarding Authority (ISA) for consideration of barring against the Protection of Children's list?*

YesNo
Have you ever been named on the Protection of Adult's list or have you ever been referred to the Independent Safeguarding Authority (ISA) for consideration of barring against the Protection of Adults's list?*

YesNo

How did you hear about us?
Please tell us how you heard about Medinet*

I received the email about upcoming medico-legal workI have been contacted by a member of the Medinet TeamI have been referred to you by my a colleagueSearch engine (e.g. Google, Yahoo)I have been directed here from NHS Jobs/IndeedI saw a post on LinkedIn/Social mediaOther
Please provide their name*

About your current post
Do you currently hold a substantive role or long term locum role in an NHS Trust or Health board?*
Please select the name of your employer*
Please select your employer type*
Please provide the name of your current employer*
Do you have any restrictions on practice at a local or regulatory level?*
Please give details*
If you would like to include any other supporting information or provide a personal statement please use the space below

Your CV and career history
Please ensure your CV includes at least your last 6 full years of employment historyworking backwards from the role you have told us about on the previous page. For any gaps in work longer than 3 months, please include an entry to provide a reason for this gap (e.g. Sabbatical, Family Break, Study Leave etc)

For any periods of time in Locum roles, please do not include details of the agency but rather the roles that you completed whilst on assignment as a locum.
Please upload an up to date copy of your CV in Word/ODT/PDF format*

CV Guidance: Please make sure your CV includes your work history up to today, with a clear indication of all previous roles, titles and locations, together with start and end dates. If your work history includes gaps in employment longer than three months, please tell us more about them (eg career break, family leave, sabbatical etc).
Cancelof

Your references
If your application is successful we will contact your provided referees for a reference to support the information you have provided in your application today.

Please note, one of your references must be from a specialist consultant with an NHS post at one of the locations on your career history from the last 12 months

If you submit your application and your references do not meet this criteria, we may contact you or reject your application.
Reference 1 - Consultant or Senior HR contact only
Their Name

First NameLast Name
Their email address*
example@nhs.net
Their home trust/hospital*
Reference 2 - Other consultant or operational manager
Their Name

First NameLast Name
Their email address*
example@nhs.net
Their employing organisation*
I consent to Medinet Clinical Services Limited to contacting the above referees for the purposes of validating the information provided in this application form.*

Clear
Print your name*

First NameLast Name
Date*

DayMonthYear
Date

Off payroll working/IR35
In providing your services to Medinet on an off-payroll basis, to support your own self-employed/outside IR35 status as well, as our own compliance obligations, it is helpful to evidence that you are indeed operating in business on your own account. We would be grateful if you can please therefore answer the following questions:
Can you confirm if you provide your services to other private and independent sector healthcare providers? For clarity, this should not include any situation where you may be working for the NHS as an employee.*

YesNo
Will you be providing your services to other private and independent sector healthcare providers concurrently with your engagement with Medinet?*

YesNo
Will your engagement with Medinet be your main source of income?*

NoYes
Please provide background as to why this is the case.*

Declaration
Being registered to work with us at Medinet doesn’t guarantee we’ll be able to offer you any work – and there’s no obligation for you, as an independent contractor, to agree to any work we might offer.

Although there’s no legal obligation for you to agree to any work we offer, we do have a cancellation policy, so that we don’t let our clients down. If you agree to take on a period of work, you’ll need to give us ample notice if you need to cancel, in line with this policy
I confirm that the information provided in this form and my CV is true and correct to the best of my knowledge*

I Agree
Signature*
Print your name*

First NameLast Name
Date*

DayMonthYear
If we are unable to offer you immediate work, we will keep your information on file and will contact you to complete onboarding at a later date. If you'd rather we didn't keep your information on file for furture opportunities, please untick the box below.

Consent
Please verify that you are human*
Should be Empty:

Hello