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Personal Details:

Gender:  male female
Are you a Car Driver?  yes no
Are you a British Citizen/ EU National?  yes no
If "no" then enter your Visa Status

Appraisals (Doctors / Nurses only)

As required by the NHS, please detail below the formal arrangements you have made to be regularly appraised by a medical practitioner entered in the specialist register. In the case of general practitioners, the appraiser must be (or qualified to be) a GP principal.

Employment History:

Reference Details:

(Please ensure you provide details of your most recent employer)

Can we contact your references immediately:  yes no

Professional Indemnity:

Please provide details of your membership.



Declaration Regarding temporary workers’ Fitness to Practice, Proceedings by a Licensing /Regulatory Body & Relating to Criminal Investigations in the UK or Overseas. Statement of criminal convictions & Police Check Clearance

Because of the nature of the work for which you are applying, this post is exempt from the provision of Section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act 1974 (Exemptions Order 1975). Applicants are, therefore, not entitled to withhold any information about convictions, which for other purposes are, then ‘spent’ under provision of the Act, and in the event of employment, failure to disclose such convictions could result in disciplinary action including dismissal being taken by the Health Authority. You are therefore required to declare all criminal convictions or cautions. Any information given will be completely confidential and will be considered only in relation to an application for positions to which the order applies and will not debar from appointment unless the selection panel considers that it renders you unsuitable for appointment. In reaching such a decision we will consider the nature of the conviction, action, how long ago it took place and any other factors that may be relevant. Failure to disclose a criminal offence, having been bound over or cautioned or that you are currently the subject of criminal proceedings which might lead to a conviction, an or der binding you over or a caution, or fitness to practice proceedings undertaken by an appropriate licensing or regulatory body, may disqualify you from appointment, or result in summary dismissal/disciplinary action and referral to the General Medical Council or General Dental Council for consideration if such discrepancy came to light.

Have you been convicted of a criminal offence, been bound over or cautioned or are you currently the subject of any police investigations, which might lead to a conviction, an order binding you over or a caution, in the UK or any other country?


If YES, please provide details of the criminal offence; order binding you over or caution or details of any current proceedings, which might lead to a conviction, an order binding you over or caution, including approximate date, the offence, the authority and the country, which dealt with the offence.

Note: Applicants for posts in the NHS are exempt from the Rehabilitation of Offenders Act 1974. You are required to declare prosecutions, including those considered “spent” under this Act.

Have you been or are you currently subject to any fitness to practice proceedings by an appropriate licensing or regulatory body in the UK or any other country.


If YES, please provide details of the nature of the proceedings undertaken, or contemplated, including approximate date of proceedings, country where the proceedings were undertaken and the name and address of the licensing or regulatory body concerned.

Have you ever been suspend from duty with any organisation or with the GMC (RGN or any other professional registration)?



Temporary Workers

Regulation 4 of the Working Time Directive requires that a temporary worker’s average working time must not exceed 48 hours per week unless the temporary worker agrees in writing to exceed the limit.

If temporary workers are to lawfully work more than 48 hours, they must sign an opt-out agreement to this affect.

If you are prepared to work more than 48 hours per week, please sign in order that we may lawfully employ you even if your hours exceed this. I agree to opt-out of Regulation 4 of the Working Time Directive.

 I agree to limit my working week to no more than 48 hrs I disagree to limit my working week to no more than 48 hrs


I confirm that I have read this document fully and that all the information given to Medilink Consulting Limited is correct to the best of my knowledge. I am not aware of any condition, medical or otherwise, which would limit or affect my employment or performance.

I acknowledge that I have been given a copy of the current terms and conditions of service issued by Medilink Consulting Ltd, and that I have read those terms and agree to abide by them. I can confirm that I am happy to agree with the Working Time Regulation notes as detailed within this document and give consent for my referee’s to be contacted for references. I understand that Medilink Consulting Ltd will process my personal data in accordance with the Data Protection act for the purposes of seeking employment opportunities.

I also understand that any personal data held by MediLink Consulting is liable to be inspected by the NHS or any framework provider as part of audit procedures.

Declaration: I confirm that the above details given by me are true to the best of my knowledge and I enclose the necessary certificates. I understand the above information may be sent to the Hospital. 

Attach Resume or other file to support: