“It is not how much you do, but how much love you put in the doing.”

Mother Teresa

    Profession
    DoctorNurseAHP/HSSOther

    Your General Practitioners Details

    British/EC National
    YesNo

    Do you hold a current Driving Licence (if so, please forward a copy)
    YesNo


    Please provide two document copies as proof of identification (e.g. household bill showing address, passport, etc). Plus two passport size photographs of yourself, signed on the back with details of your Registration number.

    Do you have your own transport
    YesNo

    Are you aware of or currently under an investigation by the GMC or any other organisation
    YesNo

    Do you have your own transport
    YesNo

    *A Legible copy of the certificate must be supplied

    Mandatory Training
    YesNo

    Are you on the specialist register
    YesNo

    Manual Handling
    YesNo

    Indicate grading of RITAS
    YesNo

    Control and Restraint
    YesNo

    Do you hold Section 12
    YesNo

    First Aid
    YesNo

    *Copies of certificates are to be supplied

    Are you a car owner
    YesNo

    Do you have an NHS Smartcard
    YesNo

    Nights
    YesNo

    Odd Days
    YesNo

    Full Time
    YesNo

    Are you registered with any other agencies
    YesNo

    Holidays
    YesNo

    Weekends
    YesNo

    Long Term
    YesNo

    Willing to travel
    0 - 50miles51 - 100 miles101 - 150 miles





    Please provide evidence of police clearance from your country of origin if you have entered this country within the past six months.
    Rehabilitation of Offenders Act 1974 (exceptions) Order 1975.

    Due to the nature of the work for which you are applying, the provision of Section 4 (2) of the Rehabilitation of Offenders Act 1974 does not apply by virtue of the Rehabilitation of Offenders Act 1974 (exceptions) Order 1975. Applicants are therefore NOT entitled to withhold information about convictions which for purposes are ‘spent’ under the provisions of the Act. In the event of employment, any failure to disclose such convictions will result in your removal from our register. Any information you may give will, of course, remain stricty confidential. CarePlus Healthcare may contact you for your permission to disclose such details if relevant to the position you are applying for.

    Have you ever been police checked?
    YesNo

    If ‘Yes’, please complete Section 12 ‘Details of any convictions’

    DBS Update Service

    Are you subscribed to the DBS Update Service
    YesNo

    Do you give permission to Chislehurst Healthcare to carry out status checks to see if the information on your DBS online profile has changed
    YesNo

    If you do give permission, Chislehurst Healthcare will notify you of any changes made that may affect your existing status.
    YesNo

    Which of the following applies to you:

    The Terms of engagement applicable to the tax status you select, can be found in the Locum Induction Handbook. Please advise your tax status as soon as possible. Chislehurst Healthcare will be unable to process any payments to you until this is supplied.

    1. PAYE

    P45 enclosed
    YesNo
    Which of these statements applies to you?
    1. ABC

    2. Limited Company/PSC

    • Enclose Certificate of Incorporation

    • Enclose Ltd Co Bank Statement

      3. Self Employed Professional


      If no UTR number is avilable, please confirm in writing that you are registered as self employed with the Inland Revenue giving your tax office address.

      1. A. This is your first job since last 6 April and you have not been receiving Taxable Jobseeker's Allowance, Employment and support allowance, Taxable incapacity benefit, state pension of Occupational Pension.

      2. B. This is your only job, but since last 6 April you have had another job, or have received taxable Jobseeker’s Allowance, Employment & Support Allowance

      3. C. You have another job or receive a state or occupational pension.


        Payment Method
        DirectTo be confirmedAgent/Umbrella

        VAT Registered
        YesNo

        Self billing

        To ensure a smooth accounting process, CarePlus Healthcare offers a Self-billing service. Contractors who are self-employed or work through PSC’s are classified as a “supplier” to CarePlus Healthcare. This allows us to pay ‘gross’ without deducting PAYE or National Insurance. However, the law requires that you issue a vatable invoice which if you sign up to self-billing we can do on your behalf.

        If you do not complete a Self-billing Agreement you will need to submit a valid invoice for the amount due to the hours you have worked plus VAT, if you are registered for VAT.

        Please refer to the CarePlus Healthcare Induction Handbook for more details.

        A Self-billing Agreement is attached.


        The Working Time regulations 1998 (“The Regulations”) require Chislehurst Healthcare to limit your average weekly working time to 48 hours unless you opt-out so that the limit shall not apply to you. Chislehurst Healthcare wishes to have an agreement with you for the following:

        Do you agree to opt-out of the 48-hour limit on average weekly time
        YesNo


        You may terminate the agreement (so that the 48 hour time limit would apply to you) by giving your Chislehurst Healthcare representative to whom you usually report 4 weeks’ written notice. Under the Regulations, Chislehurst Healthcare must keep records relating to your working time.


        Please advise by selection whether you give permission to Chislehurst Healthcare, 39 High street, Chislehurst, Kent BR7 5AE to have access to your medical records pertinent to your immunisation and blood test history.

        Do you give permission for Chislehurst Healthcare to have access to your medical records
        YesNo


        I the undersigned hereby declare that I have read and understood the Chislehurt Healthcare Induction Handbook and that I am already trained to the NHS standards in all areas. In the event that I feel I require further training in any area I will inform Chislehurst Healthcare without delay. I will ensure my annual Mandatory Training is updated and i will forward copies of certification to Chislehurst Healthcare.


        The following is a list to assist you in completing the application process. In order to avoid any unnecessary delays to your registration process please ensure you enclose original documents where requested. Please note: We will retain copies of all documentation for auditing purposes.


        Please tick to confirm documents enclosed
        A full, current CV covering the last 10 years of employment.

        Two recent passport photographs
        Authenticated as an accurate resemblance of yourself when checked against your original passport.

        Verified Personal Identification
        Please provide the original of your passport and/or birth certificate.

        Immigration Status/Eligibility to Work
        Original employment status and associated right to work documentation, including your work permit number if applicable.

        Registered Higher Qualifications
        Original documentation, to include professional qualifications, e.g. FRCP, MBBS and additional supporting documents to substantiate your CV.

        Professional Body Registration Certificate
        original registration certificate and annual retention certificate or letter of confirmation are both required.

        Professional Indemnity Insurance Certificate

        Copy of your Basic Life Support Certificate or higher.

        UK DBS Enhanced Disclosure

        2 form of identification
        to include your current address. These documents must be dated within 3 months.

        Police check from country of origin
        Original police check dated within 3 months of registration is required If you have become resident in the UK within the last six months or intend to become resident. This is in addition to the UK DBS Enhanced Disclosure.

        Immunisation reports
        Original UK serology reports which evidence immunity to MMR, Varicella, Hepatitis B Antibody levels and Tuberculosis (Also HIV, Hepatitis C and Hepatitis B Surface Antigen results are required for candidates performing Exposure Prone Procedures). All serology reports MUST be IVS approved (Identity Validated Samples).

        VAT Registration Certificate (VAT registered only)

        Signed Self-billing Agreement
        (Where applicable VAT registered applicants only)

        Copy of your Certificate of Incorporation
        (Ltd Co/PSC applicants only).

        Copy of your Ltd Co Bank Statement
        (Ltd Co/PSC applicants only).

        Copy of your P45
        (PAYE applicants only, where available)

        • I declare that the information I have supplied in this application form is complete, truthful and correct in every detail.

        • I have read the information in the Induction Handbook and the Terms of Engagement as applicable to me (in accordance with my tax status is Section 13 above) and I accept the Terms of Engagement.

        • I acknowledge that if my tax status is as a limited company/PSC by signing this application for I will be signing on behalf of the limited company/PSC and I confirm that I am authorised to do so.

        • I achnowledge and agree that by commencing an assignment (as defined in the Terms of Engagement) I will be confirming that I am willing to work in the position set out in the relevant Confirmation of Assignment Form and I acknowledge that the Terms of Engagement will be deemed to have been accepted by me upon my commencing an assignment.

        • I acknowledge and agree that if my tax status at Section 13 changes I will notify Chislehurst Healthcare and I will refer to the Induction Handbook for the Terms of Engagement applicable to my new tax status. I agree that by commencing an assignment following my change of tax status I will be deemed to have accepted the Terms of Engagement relevant to my new tax status upon my commencing the assignment.

        • I understand that my selection against Access to Medical records at Section 16 will give/refuse permission for Chislehurst Healthcare to have access to my medical records pertinent to my immunisation and blood test history.

        • I understand that it is my responsibility to undergo an annual appraisal and to supply CarePlus Healthcare with relevant information in relation to this.

        • I understand that it is my sole responsibility to update Chislehurst Healthcare in the event of any disciplinary action, investigation or changes to my professional registration.

        • I acknowledge that it is my sole responsibility to update Chislehurst Healthcare in the event of any disciplinary action, investigation or changes to my professional registration.

        • I understand Chislehurst Healthcare nay collect, use and disclose my personal information to the authority, or any person, firm or organisation duly authorised on the authorities behalf for the purpose of Audit undertaken within the Framework agreements or otherwise in accordance with the Data Protection Act 1998 and I consent to the provisions of paragraph 1.5 of the Induction Handbook relating to use of my personal data.

        • I agree that if I have given any false or misleading information, or do not give relevant information (including any change to the information I have previously provided) to Chislehurst Healthcare now or during the course of an assignment, this may result in the termination of the assignment with immediate effect.


        If any information supplied is later found to be false or misleading then Chislehurst Healthcare may terminate employment with immediate effect and refer the matter to the relevant regulatory and or professional bodies.


        By signing this declaration, you agree to the Terms of Engagement for the purpose of temporary recruitment and the declaration laid out above for Chislehurst Healthcare. This enables you to have access to work through all Chislehurst Healthcare related companies.


        Thank you for completing your application with Chislehurst Healthcare. Please return this form and all supporting documentation to your dedicated Chislehurst Healthcare recruitment consultant by hand, post, scan or email.


        The information provided will be used as part of the selection process. All information and documentation provided will now be processed through our Compliance department. Following this your dedicated recruitment consultant will be in contact with you to provide the best opportunities to suit your requirements.

        For Healthcare workers and Nurses looking for a chance to join our team:
        You can download and fill in our application form here. Once you fill in your form you can send it in via email as an attachment to careers@chislehursthealthcare.co.uk