RMR Recruitment Form

Personal Details

Surname:
Forenames:
Title:
Specialty:
Grade:
Date of Birth:
Mobile:
Home No:
Email:
National Insurance No:
Nationality:
GMC/NMC No:
Driving License:
Country of License:
Present Address:
Postcode:
Tel:

Next Of Kin Details

Name:
Relationship
Tel:
Address
Postcode:
Telephone Number:

Society/Union/Insurance

Society/Union/Insurance Type of Membership Number Renewal Date

Employment History   (please continue on a separate sheet if required)

Date From: Date To: Employers Name And Address: Job Title and Description: Specialty and Grade:

Availability

When are you available
From:
To:
Are you interested in:
Long term
Short term
Evenings
Weekends
Specialty:
Grade:
Are you willing to work away from home?
How far would you travel?
Do you own a car?

Bank Details   (Please supply proof that the account is in your name, Eg. Bank Statement)

Name of Bank:
Bank Address:
Post Code:
Account Holder:
Sort Code:
Account No:

Limited Company Details   (please supply a copy of Certificate of Incorporation and proof of bank account. If the Company is registered VAT exempt, please supply details.)

Company Name:
Company Registration No:
Company Address:
Postcode:
Sort Code:
Account No:
VAT Registration No (if applicable):

Eligibility to work in the UK

Are you a British Citizen/EC National?
If no what entry stamp was put on your passport?
Are there any restrictions on your passport to prohibit you working in the UK?
Are you subject to work permit provisions?

Service

Are you currently suspended from the GMC, NMC, an NHS Trust or relative Professional Registration Body?
Are you currently under investigation by the GMC, NMC, an NHS Trust or other Employer? If "Yes" please give details:

References

Name:
Position:
Tel:
Work address:
Post code:
email:
Fax

Name:
Position:
Tel:
Work address:
Post code:
email:
Fax

Document Check List   (Have you included/signed the following documents?)

Curriculum Vitae
Terms of Agreement
Two Passport Photographs
Proof of Qualifications
CRB/DBS Disclosure Information
NI number proof
Copy of Passport
GNC/NMC Registration Information
Medical Indemnity Certificate
Life Support/Mandatory Training
Staff Handbook Declaration
Immunisations & Health Questionnaire
If you have not already been sent the Terms of Agreement or Staff Handbook or Health Questionnaire, please indicate in the check list and we will forward you copy which just requires an online signature.

Equal Opportunities

Name:
This form is voluntary and will be kept confidential
RMR Recruitment is committed to equal opportunities in its employment policy, practices and procedures. Solely for the purposes of monitoring and evaluating the effectiveness of our policies and procedures, please could you're provide us with the following information:
Please make sure that you read all the categories listed below and then tick the appropriate boxes.
I am female
I am male
I am registered disabled
I consider myself to have a disability
If you require support or changes in your working environment in order to perform some/all of the activities relating to the job/jobs you are applying for please state below:
NB According to the Disability Discrimination Act 1995, "disability" includes any physical or mental impair- ment, which may have a substantial and/or long-term adverse effect on your ability to carry out some or all of the normal activities of the job in which you are applying.
Please make sure you read all the categories below and then tick the appropriate box that best describes your ethnic origin. Ethnic origin could be the origin of your forbearers, so it is not necessarily the same as you nationality.
I an white
or of European origin
of other origin(please specify)

I am Asian
of Indian origin
of Pakisthani origin
of Bangladeshi origin
of Chinese origin
of other origin(please specify):

I am Black
of Caribbean origin
of African origin
of other Origin(please specify):

I am of another origin(please specify)

Please tick the appropriate box for your age group
16-20
21-35
36-50
50+

General Decelaration   Please read the following declarations carefully and sign before returning.

Rehabilitation of Offenders Act
Because of the nature of the work for which you are applying, the provisions of Section 4 (2) and further Orders made by the Secretary of State under the provisions of this section of the Rehabilitation of Offenders Act (1974) (exceptions) Order 1975 apply. Applicants therefore required to give information about convictions which for other purposes are "spent" under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation for positions to which the order applies.

Have you at any time been convicted of an offence?
If "Yes" please give details:

It is a condition of proceeding with your application that you apply for an "enhanced" DBS or produce a disclosure that you have obtained within the last 12 months. Convictions and any other criminal record information obtained through the DBS disclosure service will not necessarily be a bar to employment. All circumstances will be taken into account. However, any inconsistencies compared with the information given above may invalidate your application. A full copy of the results will be forwarded to you directly by the DBS with a summary of the results sent to RMR Recruitment. This information will be retained in a secure place, and in full compliance with the Data Protection Act 1998.

Declaration
I declare that the information given here in is true and complete and is not presented in a way intended to mislead. Furthermore, I am not aware of any condition, medical or otherwise which would limit or affect my employment or performance.
I agree that if I give or have given false or misleading information, or omit to give relevant information, this may result in termination of assignment without notice, and reimbursement of any payments I have received, together with a claim for loss of any profits.
I acknowledge that I have given a copy of the current terms and conditions of service issued by RMR Recruitment, which is mine to keep, and that I have read those terms and agree to abide by them.