Registration

 

Registration



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First name:*
Last name:*
Address:*
Address 2:
Postcode:*
City:*
Phone:*
Email:*
Nationality:*
Date of Birth:*
Password:*
Confirm Password:*

Password must contain at least one number and one uppercase and lowercase letter, and at least 6 or more characters.



 

I can confirm that I have the right to work in the UK

 

From time to time we will send information to you by phone and email with information, upcoming availability & company news. If you do not want to receive these please tick below:

 

Emergency Contact


Name:*
Phone:*
Relationship:*

 

Professional Information


GMC Number:*
Smart Card Number:*
Grade:*
Speciality:*

 

Are you currently under any investigations or are there any restrictions on your practice by the GMC?

 

 

Appraisal and Revalidation


Next Revalidation Date:*
Responsible Officer:*
Next Appraisal Date:*
Name of Appraiser:*

 

By ticking this box, I confirm that I am aware of the revalidation process and I will ensure that I am appraised on a regular basis and will make Northern Health aware if any significant concerns are raised

 

Financial Information


Please select one of the following payment methods:*




UTR:
Company Name:
Company Reg Number:

 

Account Name:*
Account Number:*
Sort Code:*
NI Number:*

 

By ticking this box, I can confirm that I am fully aware and complying to IR35 guidelines and I am responsible for organising and paying my own tax, national insurance and any other HMRC issued payments & Northern Health will not be held responsible

 

Permission Declaration


Consent

In accordance with the Data Protection Act 1998 I give permission for Northern Health to


Contact & request my references

Check my online DBS & residence permit (if applicable)

Auditing my personal data on file for compliance, recruitment and quality assurance purposes internally and through third parties on occasion

 

Working Time Regulations

I can confirm I wish to work more than 48 hours per week

You can opt back in to the 48 hours regulations by putting it in writing providing 4 weeks’ notice. you must keep records relating to your hours worked, (keeping your timesheets will suffice)


 

Rehabilitation of Offenders

I confirm that


I have never been convicted, cautioned, reprimanded or given a warning by the police in any country

I have no ongoing complaints, investigations, enquiries or allegations against me

I will inform Northern Health imediately if this changes


 

NEXT STEP

Compliance 1


Doctor’s who would like to work across Mid Yorkshire NHS hospital sites (Pontefract, Pinderfields and Dewsbury) are to complete Step 2 (Compliance 1). To work at any other hospitals and in accordance with NHS Framework standards, doctors are also to complete Step 3 (Compliance 2).

 

Passport Number:*
Passport Image:*
Your CV:*
Proof of Address:*
GMC Certificate:*
Degree Certificate / RCP:*
DBS Certificate:*
Expiry Date:*
DBS Number:*
Occupational Health Results:*
Indemnity Cover for Out of Hours sessions:*
Expiry Date:*
Appraisal Date:*
Appraisal Results:*
Safeguarding Adults Training Certificate:*
Expiry Date:*
Safeguarding Children Level 3 Training Certificate:*
Expiry Date:*
Life Support Certificate:*
Expiry Date:*
PREVENT Training Certificate:*
Expiry Date:*
Mental Capacity Act (2005) Training Certificate:*
Expiry Date:*

 

Reference 1:*
Reference 2:*

The documentation above is mandatory to enable us to successfully process your registration

 

 

 

Compliance 2


To work at any other hospitals and in accordance with NHS Framework standards, doctors are also to complete this step. If not proceed to submit your details.

 

Conflict Resolution:
Expiry Date:
Manual Handling Level 2:
Expiry Date:
Fire Safety:
Expiry Date:
Complaints Handling & Lone Working:
Expiry Date:
Health, Safety & Welfare:
Expiry Date:
Counter Fraud:
Expiry Date:
Infection Prevention & Control Level 2:
Expiry Date:
Equality & Diversity:
Expiry Date:
Information Governance:
Expiry Date:

 


Please print, sign and scan the Contract and Health Clearance Questionnaire and upload the completed files here.



Health Clearance Questionnaire

 

Download
Contract Northern Health

 

Download


I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my termination.


 

By selecting this tick box, I am digitally signing up to and certifying that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my termination.