Online registration - Bluestones Medical

Personal details

Salutation

Other

Known as

Date of birth

Gender

Male Female Other

NI number

Your phone number

Your email address

Your address

Your job title

Next of kin

Relationship

Next of kin's contact number

Upload a copy of your CV and any associated documentation

Supported file types: doc, docx, rtf, txt, pdf, jpg

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

Issuing body

PIN number

Have you ever been investigated, removed or suspended by the NMC / HCPC?

Yes No

Rehabilitation of Offenders Act

Have you ever been convicted, cautioned, reprimanded or given a final warning for a criminal offence?

Yes No

Are you waiting to hear about any prosecutions pending?

Yes No

Are you aware of any police enquiries undertaken following allegations made against you, which may have a bearing on your suitability?

Yes No

Have you ever been the subject of a disciplinary investigation or proceedings by a previous employer in any position you have held?

Yes No

Consent

Please confirm that you consent to the following by ticking each statement. You must consent to each of these statements in order for us to process your registration.

Consent to 3rd party audit checks

I consent

Consent for Bluestones Medical to apply for a DBS, for DBS update service checks and retention of a copy of your DBS certificate

I consent

Consent for my personal data to be supplied to your preferred umbrella company (if applicable)

I consent

Consent to approach references

I consent

Consent to Right to Work checks

I consent

Consent to Professional Regulatory Body Checks

I consent

Consent for Bluestones Medical to provide copies of my CV, DBS and references to any prospective employer for the purposes of securing work

I consent

References

Please provide details of two references. These must cover at least 3 years of your most recent employment history.

Reference 1: Name

Reference 1: Position

Reference 1: Organisation

Reference 1: Contact number

Reference 1: Email address

Reference 2: Name

Reference 2: Position

Reference 2: Organisation

Reference 2: Contact number

Reference 2: Email address

How did you hear about Bluestones Medical?

Declaration

I hereby confirm that the information given within this form 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.

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 complete your registration by submitting this form.