Sessional GP Application Form – Local Care Direct

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.

Name

Prefix

First

Middle

Last

Date of Birth

Home Address

Contact Address (If Different from home)

Home Phone No

Mobile Phone No

Fax No

Preferred Contact No’s

Mon – Fri 09.00-17.00hrs

Out-of-Hours

Email address*

NI number

PROFESSIONAL DETAILS

Professional Qualifications

Professional Status

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

GMC Registration No

Date of full Registration

Medical Indemnity Organisation

MDU/MPS/MDDUS/Other (Please Specify)

Work/Practice, Address & Telephone No

Prescribing Code

(if applicable)

Area Team (Performers List)

EMPLOYMENT HISTORY

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

Employer

Position Held

Length of time (From - To)

Please use the space below to outline why you feel you are suited to work as a sessional GP with Local Care Direct

GENERAL

Do you possess a current driving licence?

Do you have the use of a car for travel to work?

AVAILABILITY

If successful with application when could you start?

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.

REFERENCES

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

1. Referee’s Name

First

Last

Referee’s Address

Tel. No.

Fax No.

Email address

Can they be contacted now?

2. Referee’s Name

First

Last

Referee’s Address

Tel. No.

Fax No.

Email address

Can they be contacted now?

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

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

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APPLICATION FOR WORK AS A SESSIONAL GP WITH LOCAL CARE DIRECT

PRIVATE AND CONFIDENTIAL

PROFESSIONAL DETAILS

EMPLOYMENT HISTORY

GENERAL

CONVICTIONS

REFERENCES

DECLARATION

AGENCY DECLARATION

APPLICATION FOR WORK AS A SESSIONAL GP
WITH LOCAL CARE DIRECT