Bluestones Medical Registration Form

Personal details
Title*
Name*
First Middle Last
Known as
Gender*
Date of birth*

DD
MM
YYYY
House number
Street
Town / city
County
Country
Postcode
Home phone
Mobile phone
Email*
Grade
NI Number*
Job title*

Emergency contact
Name*
First Last
Their phone number*
Their relationship to you*
Right to work
Are you legally eligible to work in the UK?*
- Yes
- No
Are you required to have a UK work visa / permit?*
- Yes
- No
Professional registration (if applicable)
Issuing body
PIN
Have you ever been investigated, removed, or suspended by a professional body?
- Yes
- No
As you answered YES to the previous question, please provide details.

Rehabilitation of Offenders Act
Have you ever been convicted, cautioned, reprimanded, or given a final warning for a criminal offence?*
- Yes
- No
As you answered YES to the previous question, please provide details.
Are you waiting to hear about any prosecutions pending?*
- Yes
- No
As you answered YES to the previous question, please provide details.
Have you ever been the subject of a disciplinary investigation or proceedings by a previous employer in any position you have held?*
- Yes
- No
As you answered YES to the previous question, please provide details.
Are you aware of any police enquiries undertaken following allegations made against you, which may have a bearing on your suitability?*
- Yes
- No
As you answered YES to the previous question, please provide details.

References
- Please complete the reference details for every employment within last 3 years (5 years if the contract requires).
- For this we require the following: The manager and organisation name (include as much detail as you can) and start/finish dates (Including month and year). Please add the e-mail address and or phone number if you can.
- If there are any gaps in your work history of over 3 months, also include a character reference.
- People providing references should work in (or be retired from) a recognised profession, have known you for at least the last two years in a professional or personal capacity, and be able to confirm your identity if required.
- People providing references should not be related / involved with an applicant - by birth, marriage, relationship, or live at the same address.
Reference 1
Name
First Last
Position
Organisation
Email address
Phone number
Start date

DD
MM
YYYY
End date

DD
MM
YYYY
Reference 2
Name
First Last
Position
Organisation
Email address
Phone number
Start date

DD
MM
YYYY
End date

DD
MM
YYYY
Reference 3
Name
First Last
Position
Organisation
Email address
Phone number
Start date

DD
MM
YYYY
End date

DD
MM
YYYY

Declarations
WTR
The WTR place a limit on the average number of hours per week that can be worked. If you are prepared to work more than the stipulated average hours per week (48 hrs) and therefore opt out of the WTR agreement, please select 'YES' below.*
- Yes - I opt out of WTR.
- No - I don't want want to opt out of WTR.
GDPR
I accept the terms outlined in the Privacy Policy.*
- Yes
- No
In order to provide you with recruitment, payroll and related services we need to acquire and retain certain information about you as an individual. We will keep this information securely, only using it for the purposes outlined in our Privacy Policy, and in full compliance with the prevailing data protection legislation. Where necessary, in order for us to complete our service to you – such as ensuring you’re paid for the work you do – we will securely pass your personal information to approved third party service providers, such as payroll agencies. We only work with other businesses that are GDPR compliant, so you can rest assured your personal information is safe and secure. You must agree to our Privacy Policy in order for us to work with you. The full Privacy Policy can be viewed online, HERE . All of our company policies are available to view online, HERE.
I agree to receive selected marketing communications from Bluestones Medical.*
- Yes
- No
From time to time, we’d like to contact you to let you know more about the services we offer, share our latest career-related blog articles or news, or let you know about exclusive offers and promotions. We’d like to do this via email, post, SMS, phone and other electronic means. We’ll always treat your personal information with the utmost care and will never sell them to other companies for marketing purposes. We will not SPAM you or bombard you with marketing communications. You can always opt out of receiving these marketing communications at any point in the future, as all our emails include an unsubscribe link.
Declaration
By submitting this form, I hereby confirm that the information given is as complete as possible, true and correct and states that I am entitled to work through an agency in the UK.

I agree that I will comply with all compliance procedures and ensure that all my documentation is present and correct.

I understand that appointment to any position is conditional on satisfactory registration and qualification checks, and that any information disclosed on this registration form will be checked.

Any offer of appointment may be withdrawn if you knowingly withhold information, or provide false or misleading information, and that registration may be terminated should any subsequent information come to light once you have been appointed.
Signature*

Bluestones Medical Registration Form

Step 1 of 6 - Personal details

Personal details

Emergency contact

Right to work

Professional registration (if applicable)

Rehabilitation of Offenders Act

Consent

References

Reference 1

Reference 2

Reference 3

Declarations

WTR

GDPR

Declaration