Sessional GP Application Form – Local Care Direct

APPLICATION FOR WORK AS A SESSIONAL GP
WITH LOCAL CARE DIRECT

Your privacy

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.

Your full name*

Your date of birth

Your home address

Your contact address (if different from home)

Your home phone No

Your mobile phone No*

Your email address*

Professional Details

Please upload your CV

Your professional qualifications

Please upload your copies of the following:

CCTGP - Certificates of completed training
PMETB - Postgraduate Medical Education & Training Board
JCPTGP - Joint Committee on postgraduate training for general practice

Your professional status

GMC registration No

Date of full registration

Your Smart Card No

Medical indemnity organisation

MDU/MPS/MDDUS/Other (Please Specify)

Please upload your indemnity certificate (which must include clear evidence of cover in OOH sessions)

Convictions

Have you ever been convicted of an offence (including motoring but not parking offences) or are any charges or summons at present outstanding against you?

If YES please give details:

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.

Please upload a copy of your DBS within the last 3 years

References

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

1st Referee's: name

1st Referee's: what is your relationship with this referee

1st Referee's: Tel. No.

1st Referee's: email address

1st Referee's: address

2nd Referee's: name

2nd Referee's: what is your relationship with this referee

2nd Referee's: Tel. No.

2nd Referee's: email address

2nd Referee's: address

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.

Applicant's Signature

Date

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.

Applicant's signature

Date

Compliance Documents

Please upload include copies of the following:

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 (Within last 12 months)
Prevent Training Certificate (Mandatory for those responsible for safeguarding level 3 within the next 3 years)
Proof of Covid Vaccination (approved evidence as per government guidelines)

Thank you

Upload*

This field should be left blank

APPLICATION FOR WORK AS A SESSIONAL GP WITH LOCAL CARE DIRECT