ID MEDICAL APPLICATION FORM

Ref: Compver2
ID Medical t: 0845 130 9331 Please attach Please attach
ID House, 1 Mill Square f: 0845 130 9335
a passport size a passport size
Wolverton Mill South e: info@id-medical.com
Milton Keynes w: id-medical.com photograph and photograph and
MK12 5ZD clearly print your clearly print your
name on the reverse name on the reverse
Please complete all sections of the application form as the information of each of each
provided on this form will be used as part of the selection process.

1. Personal Details
Title........................................................................................................... Date of Birth..............................................................................................

First Name............................................................................................... Marital Status............................................................................................

Surname.................................................................................................. Other Names............................................................................................

Sex............................................................................................................

2. Contact Details
Current Address........................................................................................ Work Telephone.......................................................................................

................................................................................................................... Ext. or Bleep...............................................................................................

................................................................................................................... Home Telephone.....................................................................................

................................................................................................................... Mobile........................................................................................................

Post Code................................................................................................. E-mail Address..........................................................................................

3. Emergency Contact Details

Next of Kin............................................................................................... 1st Contact No.......................................................................................

Relationship............................................................................................ 2nd Contact No.....................................................................................

Address............................................................................................................................................................................................................................

4. Immigration Status
British/EC National Yes  No  Permanent Resident Status Yes  No 

Passport No............................................................................................. Expiry Date..............................................................................................

Expiry Date.............................................................................................. Type of visa held (if any).......................................................................

Expiry date..............................................................................................

5. Proof of Identification
Do you hold a current Driving Licence? Yes  No  Please provide two copies of document as proof of identification
(if so, please forward a copy) (e.g. household bill showing address, passport, etc). Plus two
passport size photographs of yourself, signed on the back with
Do you have your own transport? Yes  No  details of your GMC number.

6. Bank Details
Bank Name............................................................................................... Account Name........................................................................................

................................................................................................................... ...................................................................................................................

Branch Address......................................................................................... Account No..............................................................................................

................................................................................................................... Sort Code.................................................................................................

................................................................................................................... IBAN...........................................................................................................

................................................................................................................... SWIFT/BIC..................................................................................................

Post code................................................................................................. Reference (if applicable)........................................................................

 7. Tax Status
Please select one of the following
1. PAYE 2. LTD Company 3. Self Employed Professional

Yes  No  Yes  No  Yes  No 

P45 enclosed Yes  No  Company Name....................................... NI Number......................................................

P60 enclosed Yes  No  VAT Registered Yes  No  UTR Number....................................................

NI Number................................................. Enclose Certificate of Incorporation If no UTR number is available, please

confirm in writing that you are registered
Enclose Ltd Co Bank Statement as self employed with the Inland Revenue
giving your tax office address.

Payment Method: Direct  Agent 

If Agent:
CSS  Other....................................................

8. Professional Society/Union*
Name of Society/Union........................................................................... Are you aware of or currently under an investigation
by the GMC or any other organisation? Yes  No 
...................................................................................................................
Have you ever been investigated by the
Type of Membership................................................................................ GMC or any other organisation? Yes  No 
e.g. GMC
If yes, please give details....................................................................
Renewal Date..........................................................................................
................................................................................................................
Membership No.......................................................................................
*It is the responsibility of the applicant to inform ID Medical Group
of any changes or restrictions to their registration.

9. Education and Training including Post Qualification Experience*

University / Institution / Training: Qualification: Date Graduated:

........................................................................... ........................................................................... ...........................................................................

........................................................................... ........................................................................... ...........................................................................

........................................................................... ........................................................................... ...........................................................................

........................................................................... ........................................................................... ...........................................................................

........................................................................... ........................................................................... ...........................................................................

Indicate entry on the specialist register Yes  No 

Indicate grading of RITAS (Record of In-Training Assessments) Yes  No 
Do you hold Section 12 if appropriate (e.g. Psychiatry) Yes  No 
Do you hold Certificate of Ionising Radiation if appropriate? Yes  No 

10. Professional Indemnity Insurance*

Name of Insurer............................................................................................................... Policy No................................................................................
*A legible copy of the certificate must be supplied

11. Your Availability to Work

Dates from................................................................................................ Nights Yes  No  0 - 50 miles 

Odd Days Yes  No  51 - 100 miles 
Desired location.......................................................................................
Holidays Yes  No  101 - 150 miles 
Primary grade and specialty..................................................................
Weekends Yes  No 
Secondary grade and specialty............................................................ Full Time Yes  No 
Long Term Yes  No 
Are you registered with any other agencies Yes  No 

If ‘Yes’ which..........................................................................................
 12. References (please provide two references)*

Name........................................................................................................ Name........................................................................................................

Address..................................................................................................... Address.....................................................................................................

................................................................................................................... ...................................................................................................................

................................................................................................................... ...................................................................................................................

Post code................................................................................................. Post code.................................................................................................

Telephone................................................................................................ Telephone................................................................................................

Fax............................................................................................................. Fax.............................................................................................................

E-mail......................................................................................................... E-mail.........................................................................................................

*Both references must be from within the past twelve months and one must be from your most recent/current employer.

13. Declaration of Criminal Record

Please ensure that you complete the enclosed CRB Form and will result in your removal from our register. Any information you
provide evidence of Police Clearance from your country of origin may give will, of course, remain strictly confidential. ID Medical
if you have entered this country within the past six months. may contact you for your permission to disclose such details if
relevant to the position you are applying for.
Rehabilitation of Offenders Act 1974 (exceptions) Order 1975.
Have you ever been police checked? Yes  No 

Due to the nature of the work for which you are applying, the If so, by whom?
provision of Section 4 (2) of the Rehabilitation of Offenders Act
Date you were last Police Checked
1974 does not apply by virtue of the Rehabilitation of Offenders
Act 1974 (exceptions) Order 1975. Applicants are therefore Have you ever been convicted
NOT entitled to withhold information about convictions which of a criminal offence? Yes  No 
for purposes are ‘spent’ under the provisions of the Act. In the
If ‘Yes’, please complete Section 14 ‘Details of any convictions’
event of employment, any failure to disclose such convictions

14. Details of any convictions

Offence: Date of conviction: Sentence:

........................................................................... ........................................................................... ...........................................................................

........................................................................... ........................................................................... ...........................................................................

........................................................................... ........................................................................... ...........................................................................

........................................................................... ........................................................................... ...........................................................................

........................................................................... ........................................................................... ...........................................................................

15. Your General Practitioners Details

Name............................................................................. ..........................................................................................

.......................................................................................... ..........................................................................................

Address......................................................................... Post code.....................................................................

.......................................................................................... Telephone....................................................................

16. Appraisal Details*

Please supply name of Medical Practitioner/GP Principle who is entered on the specialist register with whom formal arrangements have
been made to be regularly appraised*:

Doctor’s name.................................................................... *Please supply details of your Continual Professional Development

(CPD) action plan.
Date last appraised**........................................................

**Please supply a copy of the transcript of your last appraisal.

Date of next appraisal.......................................................
17. Declaration
I understand that it is my responsibility to undergo an annual
appraisal and attend mandatory training in the following disciplines:
Moving and Handling; Health and Safety; Fire Safety Procedures;
Infection Control; COSHH; RIDDOR; Risk Incident Reporting;
Complaints Handling; Lone Worker Training; Information Security;
Handling of Violence and Aggression; Cross Infection; Computer
use; Notifiable diseases; Clinical governance; Data Protection
Act 1998; Ionising Radiation; The Caldicott Principle; Working time
directive: this list is not an exhaustive one, however it reflects the
types of training and development needed to undertake your
current role and responsibilities.
18. Checklist
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 tick to confirm documents enclosed
 Please supply a full, current CV covering the last 10 years of
employment.
 Application Form.
Please ensure this is completed in full, signed throughout
where required including the Pre-employment screening
questionnaire.
 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.
Please provide your original employment status and
associated right to work documentation, including
your work permit number if applicable.
 Registered Higher Qualifications.
Please provide your original documentation, to include
professional qualifications, e.g. FRCP, MBBS and additional
supporting documents to substantiate your CV.
 GMC Registration.
Please provide your original GMC registration certificate and
annual retention certificate or letter of confirmation.
 Professional Indemnity Insurance.
Please provide a copy of your professional indemnity
insurance certificate (if held).
Signature..................................................................................................
Print Name................................................................................................
Date..........................................................................................................
GMC Number...........................................................................................
 UK CRB Enhanced Disclosure.
Please complete and return the CRB Application Form
enclosed with your registration pack in black ink only.
We will on receipt of your CRB application form, transfer
all relevant information onto our online CRB Application
system to speed up the process. Please provide 2 forms
of identification to include your current address. These
documents must be dated within 3 months and can be
returned to you if requested.
 Police check from country of origin.
If you have become resident in the UK within the last six
months or intend to become resident, you will need to supply
us with an original police check from your country of origin.
This must be no more than three months old at the time
of registration. This is in addition to the UK CRB Enhanced
Disclosure.
 Immunisation.
Please provide original UK serology reports to demonstrate
evidence of immunity to MMR, Varicella, Hepatitis B Surface
Antigen levels, Hepatitis B Antibody levels, Hepatitis C, HIV
and Tuberculosis. Please note that HIV, Hepatitis C and
Hepatitis B Surface Antigen results are only required for
doctors performing Exposure Prone Procedures. All serology
reports MUST be IVS approved (Identity Validated Samples).
 A copy of your Basic Life Support certificate or higher.
 A copy of your Certificate of Incorporation
(Ltd Co. applicants only).
 A copy of Ltd Co Bank Statement
(Ltd Co. applicants only).
 19. Working Times Regulations
The Working Times regulations 1998 (“The Regulations”) require If you accept the company’s proposals, please sign below.
ID Medical to limit your average weekly working time to 48 hours This document will then be the record of agreement.
unless you agree with ID Medical that the limit shall not apply
to you. ID Medical wishes to have an agreement with you. It
proposes an agreement (which will apply until terminated by
notice) on the basis that: Signed..........................................................................

1. The 48-hour limit on average weekly time will not apply to you. Print name...................................................................

2. You may terminate the agreement (so that the 48 hour time Date................................................................................
limit would apply to you) by giving the person at ID Medical
to whom you usually report 4 weeks’ written notice. Under the GMC Number..............................................................
Regulations, ID Medical must keep records relating to your
working time. This is the case whether or not you reach an
agreement with ID Medical about waiving working time limits.

20. Mandatory Induction, Information & Training Declaration

I the undersigned hereby declare that I have read and understood the ID Medical Locum Guide and Information Booklet and that I
am already trained to the NHS standards in all the areas.

In the event that I feel I require further training in any area I will inform ID Medical without delay.

I fully understand that should any information that I have presented within this application comes to light, following my employment
with the prospective employer, which shows that this declaration was found to be mis-represented, or false, my employer may
terminate my employment with immediate effect.

Signed.......................................................................... Date..............................................................................

Print name.................................................................... GMC Number...............................................................

21. Access to Medical Records

I the undersigned hereby give permission to ID Medical, ID House, 1 Mill Square, Wolverton Mill South, Milton Keynes, MK12 5ZD to have
access to my medical records pertinent to my immunisation and blood test history.

Signed.......................................................................... Date..............................................................................

Print name.................................................................... GMC Number...............................................................

22. Declaration
I the undersigned hereby declare that the information I have given in this application form is true to the best of my knowledge and
belief. I agree that if I have given any false or misleading information, or do not give relevant information now or in the future, this may
result in termination of an assignment without notice.

I acknowledge that I have been given a copy of the Terms and Conditions and access to the Locum Guide pack by ID Medical
and I will abide by those Terms and Conditions.

Furthermore I hereby consent to ID Medical disclosing to the Authority, or any person, firm or organisation duly authorised on the
Authority’s behalf or NHS Government Procurement Solutions (GPS) documentation for the purposes of an external audit required
in accordance with the NHS GPS National Framework Agreement.

Signed.......................................................................... Date..............................................................................