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  • National Locums Registration Form

    Personal Details


























































































  • Emergency Contact Details

    In case of an emergency - Please provide your next of kin:














  • Declaration of Permission to Work in the UK












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  • If 'no' please state your nationality: tick the appropriate box of your right to work status and Nationality:










































  • Professional Indemnity

    We recommend that you take membership of a Medical Degree Organisation. If you are a member please provide details of your membership with a copy of your certificate.




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  • Education & Professional Training

  • Professional Registration

    Please tick all professional bodies that you are currently registered with. Please include the registration number.




































  • Payment Details

    Umbrella (for work in NHS) - Please see our the PSL page on our website.

  • Please note: if your preferred umbrella is not on our PSL, please contact your National Locums consultant.

  • Appraisal Details

    Please provide details of the formal appraisal and revalidation arrangements.



























































  • Mandatory Training

    Have you ever had initial training in the following? Where you have answered yes, please give dates of training and provide copies of your certificates.




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  • Vaccination History












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  • Declaration of Criminal Record

    Because of the nature of the work for which you are applying, the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974 do not apply by virtue of the Rehabilitation of Offenders Act 1974 (Exemptions Order 1975). Applicants are, therefore, not entitled to withhold any information about convictions, which for other purposes are, then ‘spent’ under provision of the Act. In the event of employment, failure to disclose a criminal offence, having been bound over or cautioned or that you are currently the subject of criminal proceedings which might lead to a conviction, an order binding you over or a caution, or fitness to practice proceedings undertaken by an appropriate licensing or regulatory body, may disqualify you from appointment, removal from our register, and referral to the General Medical Council or General Dental Council for consideration if such discrepancy came to light. Any information given will be completely confidential and will be considered only in relation to an application for positions to which the order applies and will not debar from appointment unless the selection panel considers that it renders you unsuitable for appointment. In reaching such a decision we will consider the nature of the conviction, action, how long ago it took place and any other factors that may be relevant.













































  • If you have answered yes to any of the above questions please provide further information on the personal declaration form. I understand that if at any stage I am charged or cautioned after signing this declaration, I must inform The GP Team immediately

  • Referee Details

    Current Employment










































  • Most recent previous position
















































  • Previous Position













































  • Working Time Directive Opt Out Agreement

    Regulation 4 of the Working Time Directive requires that a temporary worker’s average working time must not exceed 48 hours per week unless the temporary worker agrees in writing to exceed the limit.If temporary workers are to lawfully work more than 48 hours, they must sign an opt-out agreement to this affect. If you are prepared to work more than 48 hours per week, please tick the below box. If you do not wish to work more than 48 hours per week please DO NOT tick the below box. Please sign and return the agreement below as soon as possible in order that we may lawfully employ you even if your hours exceed this.







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  • PLEASE READ BEFORE SIGNING

  • Candidate Declaration - I declare that I have received, read and understood the National Locums Handbook and Terms of Business. I agree to abide by the Terms of Business and the Handbook.• I consent to National Locums requesting a Disclosure and Barring Service (DBS) check and understand that any fees associated are payable by myself. I consent to National Locums requesting a DBS status update on my behalf.• I consent to National Locums requesting appropriate references on my behalf.• I declare that the information I have given in this application form is true and not in any way intended to mislead. I agree that if I have given false or misleading information or if I do not give relevant information now or in the future, this may result in termination of an assignment and removal from National Locums register without notice.• I consent to National Locums to make available my information to third parties for the purpose of audit.• I acknowledge that if any of my details stated on the Application Form change, or my circumstances change in any way which may affect my ability to work for National Locums. I must inform National Locums immediately.• I understand that I need to keep any relevant training up to date and should I feel I require further training in my specialty, I will inform National Locums immediately. I understand that any fees associated are payable by myself.• I confirm that I am not currently under investigation, or currently suspended by any professional regulatory bodies or being investigated by my current or previous employer. I will inform National Locums immediately if I become under investigation or suspended by any professional regulatory body or employer at any point whilst working for National Locums.• I declare that by signing this form I am stating that I am legally entitled or allowed to work in the United Kingdom, with or without necessary permission from the Home Office or any other relevant authority if I have secured permission to work. I also acknowledge that if it is found that I am working without the relevant permission, my engagement with National Locums will be terminated with immediate effect, and all details passed to the relevant authorities.• I understand it is my responsibility to engage in the revalidation process including participating in annual appraisals. Working Time Directive Opt Out Agreement Regulation 4 of the Working Time Directive requires that a temporary worker’s average working time must not exceed 48 hours per week unless the temporary worker agrees in writing to exceed the limit. If temporary workers are to lawfully work more than 48 hours, they must sign an opt-out agreement to this affect. If you are prepared to work more than 48 hours per week, please tick the below box. If you do not wish to work more than 48 hours per week please DO NOT tick the below box. Please sign and return the agreement below as soon as possible in order that we may lawfully employ you even if your hours exceed this. Print Name:Signature:Date:I agree to opt-out of Regulation 4 of the Working Time Directive.


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