New Medical Application Form JULY 2009

8/3/2019 New Medical Application Form JULY 2009

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IN CONFIDENCE

MEDICAL STAFF APPLICATION FORM

Please complete this form and the attached Equal Opportunities MonitoringForm in black ink or type and return to: Medical HR Department, RoyalBrompton & Harefield NHS Trust, Sydney Street, London, SW3 6NP.

Post Applied For:

Reference Number:

Surname: Firstname:

Home telephone number: Mobile:

Contact Address:

E-mail Address: National Insurance No:

GMC No: Specialist Registration: Yes/No* (if noplease provide details)


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Qualifications:Include in this section all the

relevant qualifications.

Please also indicate subjects

currently being studied. All

qualifications disclosed will

be subject to a satisfactory

check.

University/MedicalSchool/Academic Body

DateObtained

Class ofDegree


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Present Appointment Hospital From To

Previous AppointmentsPlease record below thedetails of your previousemployment, beginning withthe most recent first.

Hospital From To


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Suporting Information

*Describe your experience of clinical audit.

*Describe your relevant teaching experience


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*Details of your most relevant research work and piblications in peer-reviewed journals

*Please explain your area of clinical skill and competence relevant to this post


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*Give examples of your approach to working in a team.

*Please provide any other supporting information that you think may be helpful, or that isrequested in the person specification. Please ensure this does not include any duplicateinformation already provided elsewhere in the application form or any personal details


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IMMIGRATION STATUS:

1 Are you a United Kingdom (UK), European Community (EC) orEuropean Economic Area (EEA) national? (Please circle asappropriate)

YES NO

2 If not, do you have evidence of entitlement to enter and workpermanently in the United Kingdom i.e settled status? (Pleasecircle as appropriate)

YES NO

If you have circled yes to Question 2 in the above section please tick thoseboxes that relate to your current immigration status:

Tick Status Expirydate

Highly Skilled Migrant Programme

Certificate of Sponsor/visa (Tier 2 General)

Any other please specify

Have you been granted indefinite leave to remain? If yes pleasedisclose date valid from

.

GMC Registration Number: Full/Limited/Provisional (please circle)

Renewal Date:REFERENCES

Please state the names, address, email, fax and telephone details of the people who haveagreed to supply references covering a minimum of three years employment/training. If

you are or have been employed it is essential that you include your two most recentemployers, your line manager or someone in a position of responsibilitywho cancomment on your work experience, competence, personal qualities and suitability for the

post. If you have undergone training to return to work then academic institution shouldbe contacted.

Personal references such as friends and relatives are not acceptable and all refrences will

be sought and employment history verified through the organisations centeral Humanaresourcse /Personnel Departement or equilivent, therefore, please ensure that youprovide their full contact details.


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1.

TEL:: FAX:

E-MAIL:

2.

TEL: FAX:

E-MAIL:


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REHABILITATION OF OFFENDERS ACTRehabilitation of Offenders Act 1974 does not apply to this appointment. The TrustBoard, therefore, in order to protect patients, has the right to obtain all relevantinformation including details of criminal convictions (if any) about the applicant beforefilling the post; you are therefore asked to reveal any such relevant information which willof course be kept strictly confidential.

Have you any unspent criminal convictions bind-overs, cautions,warnings or reprimands?

Yes No (Please tick as appropriate)

If yes, please give details. (include separate sheet if necessary)

.....

....

Have you at any time received or had pending a criminal conviction,caution, warning, reprimand or bindover?

Yes No (Please tick as appropriate)

If so, please give details. (include separate sheet if necessary)

.........

DECLARATIONI declare that the information I have given in this application is correct to the best ofmy knowledge. I understand that, in the event of employment, I could be dismissedif I have deliberately given false information. I am prepared to have a medicalexamination if asked to do so.

Signature: ..............................................................Date: ..................................................

Documents

New Medical Application Form JULY 2009