Application Form

1. Personal Details

Title ............................................................. Sex ...........................................................

First Name .................................................. Middle Name ............................................
Surname ..................................................... Marital Status ............................................

2. Contact Details

Current Address .......................................... Contact Number .......................................

.................................................................... Mobile .......................................................
.................................................................... Work Number............................................
.................................................................... Ext/Bleep Number.....................................
Postcode..................................................... Email .........................................................

3. Emergency Contact Details

Next of Kin .................................................. Relationship ..............................................

Contact Number.......................................... 2nd Contact Number ................................

4. Immigration Status:

British/EC Citizen Yes n No n Passport Number ......................................

Permanent Resident Yes n No n Issue Date .................................................
Work Permit Holder Yes n No n Expiry Date ...............................................
 5. Equal Opportunities Monitoring

Surgi-Call are an Equal Opportunity Recruitment Agency. We therefore ensure all

applicants are submitted for vacancies based solely on the basis of merit. In order for us to
monitor the effectiveness of our policy, we ask that all applicants to provide the information
requested below. Surgi-Call thank you in advance for your co-operation:

Male n Female n Age Group 16-20 n 21-35 n 36-49 n 50+ n

Would you consider yourself to have a disability: Yes n No n

If yes please provide further details of the same ..................................................................

Please ensure you read all the categories listed below and tick the appropriate box that
best describes your ethnic origin. As this could be the origin of your antecedents, it is not
necessarily the same as your nationality.

n White n Black-Caribbean n Indian n Bangladeshi n Mixed

n Black-African n Black-other n Pakistani n Chinese n Other

6. Identification Checks

Please provide two copies of proof of identification (e.g. household bill showing address,
passport etc) along with two passport photographs, signed on the back including your
GMC number.

7. Bank Details

Bank Name ................................................. Account Name ..........................................

Address ...................................................... Account Number .......................................
.................................................................... Sort Code ................................................
....................................................................
Postcode ....................................................

8. Taxation Details

Please select one of the following to confirm your status along with relevant
enclosed documents.

PAYE Yes n No n Self Employed Yes n No n Limited Company Yes n No n

n P45 Tax Ref Number Company Name

n P46 ............................................. .............................................
VAT Registered Yes n No n
n Certificate of Incorporation
n Company Bank Statement
 9. Professional Society *

Name of Society ......................................... Type of Membership .................................

Renewal Date .............................................. Membership Number ................................

Please confirm whether you are currently under investigation by the GMC or any other
professional organisation Yes n No n
Have you even been investigated by the GMC
or any other professional organisation Yes n No n
If yes, please give further details .........................................................................................

...........................................................................................................................................

* Please be advised that it is the responsibility of the applicant to inform Surgi-Call of any changes or
restrictions to their registered professional body.

10. Professional Indemnity Insurance *

Name of Insurance Company..............................................................................................

Policy Number........................................................

* Please ensure that you kindly provide a copy of your insurance certificate.

11. Post Qualification Training

Are you currently registered on the specialist register? Yes n No n

Indicate grading of RITAS (Record of In-Training Assessments) Yes n No n
Do you currently hold Section 12 if appropriate? Yes n No n
Do you currently hold Certificate of Ionising Radiation if appropriate? Yes n No n

12. Education and Professional Training

University ............................................................................................................................

Qualification .......................................................................................................................

Date Completed .................................................................................................................

 13. Employment History

Current/Most Recent Employer ...........................................................................................

Address .............................................................................................................................
Start Date ................................................... Finish Date ................................................
Grade ......................................................... Specialty ...................................................

Previous Employer ..............................................................................................................

Address .............................................................................................................................
Start Date ................................................... Finish Date ................................................
Grade ......................................................... Specialty ...................................................

Previous Employer ..............................................................................................................

Address .............................................................................................................................
Start Date ................................................... Finish Date ................................................
Grade ......................................................... Specialty ...................................................

Previous Employer ..............................................................................................................

Address .............................................................................................................................
Start Date ................................................... Finish Date ................................................
Grade ......................................................... Specialty ...................................................

Previous Employer ..............................................................................................................

Address .............................................................................................................................
Start Date ................................................... Finish Date ................................................
Grade ......................................................... Specialty ...................................................

14. Availability for Locum Work

Part Time Yes n No n Full Time Yes n No n Nights Yes n No n

Weekends Yes n No n Long Term Yes n No n Annual Leave Yes n No n
Odd Days Yes n No n

15. Are you registered with any other locum agencies:

If so please kindly detail below: ..........................................................................................

...........................................................................................................................................
 16. Reference Details

Please ensure that both references are within the last 12 months and represent the 2 most
recent work placements. One referee can be from your current employer.

17. Appraisal Details

Please name a Medical Practitioner/GP Principal who is registered on the specialist

register with whom formal arrangements have been made to be regularly appraised.*

Appraiser’s Full Name .........................................................................................................

Appraiser’s GMC Numbers ........................... Appraiser’s Position .................................

Date of Last Appraisal ..................................... Date of Next Appraisal .............................

*Please supply details of your Continual Professional Indemnity (CPD) action plan

** Please supply a copy of the transcript of your last appraisal

18. Declaration of Criminal Record

You will also be asked to kindly complete the enclosed CRB Application Form and provide
evidence of Police Clearance from your country of origin if you have entered the UK within
the past six months.
Rehabilitation of Offenders Act 1974 (exceptions) Order 1975
Because of the nature of the work for which you are applying, the provision of Section 4 (2)
of the Rehabilitation of Offenders Act 1974 does not apply by virtue of the Rehabilitation of
Offenders Act 1974 (exceptions) Order 1975. Applicants are therefore NOT entitled to
withhold information about convictions which for purposes are “spent” under the provision
of the Act. In the event of employment, any failure to disclose such convictions will result in
your removal from our register. Any information you may give will, of course, remain strictly
confidential. Surgi-Call may contract you for your permission to disclose such details if
relevant to the position you are applying for.
Have you ever been police checked: Yes n No n

If so, by who ......................................................................................................................

Date you were last police checked .....................................................................................

If “yes” please complete section 19

 19. Details of any convictions

Offence Date of conviction Sentence

20. Document Checklist

The following is a list to assist you in completing the application process. In order for
Surgi-Call to process your application swiftly please ensure that you enclose original
documents where requested:
n Application Form. Please ensure that this is completed in full and signed throughout
where required including the Pre-employment screening questionnaire.
n A copy of your most recent CV in word format including details of 2 referees from your
current or most recent placement.
n Verified Personal Identification. Please provide your original passport and/or birth
certificate.
n Registered Higher Qualifications. Please provide your original passport to include
professional qualification e.g. FRCP and additional supporting documents to
substantiate your CV.
n GMC registration. Please provide your original documentation to support your original
entry to the GMC along with your annual retention certificate.
n Recent photograph authenticates as an accurate resemblance of yourself when
checked against your original passport.
n Immigration Status/Eligibility to work. Please provide your original employment status
and associated right to work documentation, including your work permit number if
applicable.
n Professional Indemnity Insurance. Please provide a copy of your professional indemnity
insurance.
n UK CRB Enhanced Disclosure. Please complete and return the CRB Application
provided separately. Surgi-Call are no longer able to use CRB disclosures from any
other agency or employer.
n Police Check from country of origin. If you have entered the UK within the last six months
prior to recruitment you are obliged to provide an international police check from the
country of origin. This may either be your place of permanent residence or place you were
visiting. Please note that the police check must be no more than three months old at the
time of recruitment.
n Blood serology reports. Please provide original documents clearly showing immunity to
Hepatitis B, Measles, Mumps, Rubella, Varicella and TB. Candidates performing
Exposure Prone Procedures (EPP) please also provide evidence of immunity to
Hepatitis B Surface Antigen, Hepatitis C and HIV test 1 & 2.
 21. Pre-employment screening questionnaire

Please ensure that you kindly provide evidence of the following conditions:
Reports should be in the form of a UK CPA accredited lab report which should include an
IVS Stamp – Identified Validated Sample. We regret we are unable to accept foreign
medical reports.
The following documents MUST be supplied in a sealed envelope:
n Hepatitis B demonstrating antibody titre levels of >100 miu/ml
n Measles
n Mumps
n Rubella demonstrating antibody titre levels of >15 miu/ml
n Varicella – Candidates are no longer in a position to self declare previous infection
to Varicella
n TB
n Candidates performing Exposure Prone Procedures are required to provide evidence
of immunity to the following in addition to the above. These reports must be Identified
Validated Samples (IVS)
n Hepatitis B Surface Antigen
n Hepatitis C
n HIV Test 1 & 2
Please tick to confirm that you have immunity to the following conditions:
Diptheria Yes n No n
Polio Yes n No n
Tetanus Yes n No n

22. GP Details

Name .......................................................... Contact Number .......................................

Address ..............................................................................................................................
Postcode ....................................................
Applicant’s NHS Number....................................................
 23. BCG Scar Sighting

If you have evidence of a scar please have a Occupational Health physician cite that they
have verified the scar.

This is to certify that Dr .............................................. GMC .........................................

Has a BCG scar present .....................................................................................................

Verified by (Name) ...............................................................................................................

Job Title .............................................................................................................................

Qualification ........................................................................................................................

Occupation Health Department if applicable .......................................................................

Please insert in the box below the Occupational Health Department Stamp if applicable
 24. Medical History

Does your employment involve any of the following:

Driving Yes n No n
Night work Yes n No n
Moving and handling of patients Yes n No n
Exposure to radiation Yes n No n
Exposure to chemicals/biological agents Yes n No n
Exposure to blood and/or bodily fluids Yes n No n
Exposure to serious communicable diseases Yes n No n
Working with skin irritants Yes n No n
Visual Display Unit for more than 1 hr per day Yes n No n

Other significant hazards.....................................................................................................

Please indicate whether you have ever suffered, or had problems relating to any of the
following conditions:

Rheumatism/Arthritis Yes n No n
Epilepsy/fits/blackouts Yes n No n
Migraine/headaches Yes n No n
Diabetes Yes n No n
Dizziness/fainting Yes n No n
Rheumatic fever Yes n No n
Alcohol related problems Yes n No n
Eyesight problems not corrected by spectacles or contact lenses Yes n No n
Hearing problems not corrected by hearing aid Yes n No n
Nervous disorder/mental illness/nerves/anxiety/depression/
phobias/anorexia Yes n No n
Muscular skeletal problems including back problems Yes n No n
Palpitations/heart problems/angina Yes n No n
Cardiovascular problems Yes n No n
Asthma/bronchitis/chest problems Yes n No n
Allergic reaction to personal protective equipment
e.g. gloves, masks etc? Yes n No n
Would you consider yourself to have a disability Yes n No n
Are you currently seeking medical advice Yes n No n
Are you currently taking any medication Yes n No n

If yes please provide details of the same along with dosage of medication .........................

...........................................................................................................................................

Please provide details below of any serious illness, hospital admission, operation or
accident that has caused you to have five or more days off work in the last five years.

...........................................................................................................................................

...........................................................................................................................................

...........................................................................................................................................

...........................................................................................................................................

Are you aware of any known allergies .................................................................................

Number of days sick in the last five years, please provide details ........................................

...........................................................................................................................................

25. The Disability Discrimination Act

This Act makes it unlawful to discriminate against disabled persons in connection with
employment. A person has a disability for the purposes of the Act if he or she has a
physical or mental impairment which has a substantial and long term adverse effect on his
or her ability to carry out day-to-day activities. To comply with the law an employer needs
to know if you consider yourself disabled.

Do you have a disability as defined above? Yes n No n

If so please provide details ..................................................................................................

...........................................................................................................................................

...........................................................................................................................................

Please outline below what suitable adjustments you need for your disability .......................

...........................................................................................................................................

...........................................................................................................................................
 26. Declaration

I the undersigned agree to the following:

I the undersigned hereby consent for Surgi-Call to verify the information relating to this
application in order to comply with governed recruitment procedures and to satisfy the
interests of patient safety. Furthermore I consent for information held by Surgi-Call about
me to be viewed by the authority/NHS PaSA as necessary.

I understand that it is my responsibility to undergo an annual appraisal and attend

mandatory training in the following disciplines:

Moving and Handling, Health and Safety, Fire Procedures, Infection Control, COSHH,
RIDDOR, Risk Incident Reporting, Complaints Monitoring, Lone Worker Training

Termination of Employment
I understand that should any information come to light following any employment that I
undertake, which shows that any information or medical information disclosed by myself in
this application was found to be misleading or false, my employer has the right to
terminate my contract with immediate effect.

Working Time Regulations

The Working Times Regulations 1998 (“The Regulations”) require the Company to limit
your average weekly working time to 48 hours unless you agree with the Company that
the limit shall not apply to you.

The Company wishes to have an agreement with you. It proposes an agreement (which
will apply until terminated by notice) on the basis that:

• The 48 limit on average weekly time will not apply to you.

• You may terminate the agreement (so that the 48 hour time limit would apply to you) by
giving the Company 4 weeks written notice.

Under the Regulations, the Company must keep records relating to your working time.
This is the case whether or not you reach an agreement with the Company about waiving
working time limits.

If you accept the Company’s proposal, please sign below.

Mandatory Induction Information & Training Declaration

I declare that I have read and understood the Surgi-Call Induction Handbook, and that I
am already trained to NHS standards in all these areas. Should I feel I require training in
any area I will contact Surgi-Call immediately. I acknowledge that I have been presented
with a copy of the Terms and Conditions enclosed within the Induction Handbook and I
confirm that I will abide by those Terms and Conditions.

Name .......................................................................... GMC .........................................

Signature .................................................................... Date .........................................

 27. Medical Consent

I declare that the information that I have given is to the best of my knowledge, a true and
complete account of my medical history. I hereby give consent for Surgi-Call to access my
medical records pertinent to my immunisation and blood test history.

Name .......................................................................... GMC .........................................

Signature .................................................................... Date .........................................