Bluestones Medical Registration Form

• 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.

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Any offer of appointment may be withdrawn if you knowingly withhold information, or provide false or misleading information, and that registration may be terminated should any subsequent information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.