IMS

UK Recruitment Assessment Form

Date:
Drs Details Ref number: Consultant:
Name:

Current situation:

Notice Period:

Available Date:

Preferred Location:

Contract Duration: 6mth 1yr 2yr Other :__________

Rotation pref. 1:1 2:1 ABCD Other

Salary Per Rotation

1:1 - £11.90 ph incl hp 2:1 - £10.41 ph incl hp ABCD - £18 ph incl hp

£2,000 pw £1,750 pw £1,512 pw
£52,000 pa £68,250 pa £39.310 pa

End of Contract Bonus

£500 – 6 months £1,250 – 12 months £2,750 – 24 months

Have you worked with Paediatrics? Y N if Yes no. mths_____________

Level of English: 1 2 3 4 5 IELTS

Additional Checks

GMC Full Full – APS Other (eg lapsed) _______________ GMC No: __________

Visa Status _______ WP Required Request copy of RTW

Resus Courses
ALS Yes Date _________ No EPLS Yes Date _________ No
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 IMS
Recruitment

Doctors Original CV CV Template Registration Form

Placement Details MSM: Phone No.:

SI Date: Pass Failed Review Give reason:

SI Time: Rotation: Start Date:

Possible placement: Confirm Salary: Duration confirmed in SI:

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