APPLICATION FOR WORK AS A SESSIONAL GP
WITH LOCAL CARE DIRECT

 

PRIVATE AND CONFIDENTIAL

The information provided on this form will help us to assess your suitability to work with Local Care Direct. Please answer the questions fully and complete clearly. All information will be treated in strictest confidence. The last page of this form is designed to enable us to monitor our equal opportunities policy. The information, which you provide, will be treated in the strictest of confidence and will not be used in any way when assessing your suitability to work with us.

Preferred Contact No’s

PROFESSIONAL DETAILS

GP Principal/Registrar/Locum/Retired (Please Specify)

MDU/MPS/MDDUS/Other (Please Specify)

(if applicable)

EMPLOYMENT HISTORY

Please give details of all current positions held (previous employment should be detailed on your Curriculum Vitae)

GENERAL

AVAILABILITY

CONVICTIONS

NOTE: By virtue of the Rehabilitation of Offenders Act 1974, Section 4(2) of the Rehabilitation of Offenders Act 1974 does not apply to this question. You are therefore not entitled to withhold information about a previous conviction on the grounds that it is for other purposes spent under the Act.

REFERENCES

(One of which should be your current or most recent employer)

DECLARATION

(Please read carefully, then sign and date your application)
I confirm that the information I have provided is correct and understand that misleading statements may be sufficient grounds for cancelling any agreements made. I also understand that questions left unanswered may be discussed at interview(s) arising from this application.

 AGENCY DECLARATION

(Please read carefully, then sign and date)
If you have been, or currently working for an Agency, it is your responsibility to check with the Agency that you are available to work for Local Care Direct directly and that LCD will not incur any financial penalties. If financial penalties are incurred they will be your responsibility to cover. I acknowledge the content of the above declaration and agree to its terms.
Please remember to include copies of:  
  • Smart Card Number
  • GMC Number
  • CV
  • Indemnity Certificate (To include clear evidence of cover in OOH sessions)
  • CCTGP - Certificates of completed training
  • PMETB - Postgraduate Medical Education & Training Board
  • JCPTGP - Joint Committee on postgraduate training for general practice
  • Final page of appraisal document
  • Area Team letter confirming you are on the performers list
  • DBS within the last 3 years
  • Proof of NI (eg: Payslip or NI card
  • Proof to work in UK (eg: UK Passport)
  • Safeguarding Children Level 3 (Within last 3 years)
  • Safeguarding Adults Level 2 (Within last 3 years)
  • Mental Capacity Act 2005 Certificate (Within last 3 years)
  • Basic Life Support/ CPR
  • 2 X References
  • Date of next appraisal/re-validation
  • Prevent Training Certificate (Mandatory for those responsible for safeguarding level 3 within the next 12 months)
  Please return this Application Form along with the Equal Opportunities Monitoring Form to: Rubina Tai, Rota Team, Local Care Direct, Unit 2 Longbow Close, Pennine Business Park, Bradley, Huddersfield, HD2 1GQ