Application Form | GENESIS Solutions

Title

First Name

Surname

Previous Name

Gender

Date of Birth

National Insurance Number

Name of Bank or Building Society

Address

Name of Account Holder

Account Number

Grade/Speciality

NMC PIN Number

Expiry Date

Unison/RCN

Do You Have a Current DBS?

Yes

No

Date DBS Issued

DBS Number

Police Clearance

Yes

No

Date Issued

Address & Postcode

Home Contact Number

Mobile Contact Number

Work Contact Number

Facsimile

Email

Employment History: Please detail all employment covering the last ﬁve years (most recent ﬁrst).

Do you have any business interests (paid or otherwise) that may affect your ability to adhere to your contract with Genesis International Solutions?

Yes

No

Professional References: Please give the details of at least two professional referees from your most recent periods of employment, covering at least five years. They must have held a more senior position than you.

Right to Work in the UK: I have the approval of Home Office and Department of Employment to work for a UK Agency. I declare that there are no reasons on my Resident permit, which prevent me from accepting a locum agency’s job offer.

Yes

No

Have you worked with children in an NHS trust in the last 12 months?

Yes

No

If yes, please state the trust name:

Have you been in the subject of 'fitness to practice'?

Yes

No

Have you been suspended with the NMC or from any other organisation before?

Yes

No

Have you ever been convicted of an offence other than a road traffic violation?

Yes

If yes to any of these, please provide further information:

If other, please give details:

The Equality Act 2010: The Equality Act 2010 defines a person with a disability as someone who has a physical or mental impairment which has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities. DO YOU CONSIDER YOURSELF TO HAVE A DISABILITY?

Yes

No

If yes, please describe the nature of your disability:

Apply to Work With Us