Application Form


    Please note: Your name should be in full, as appearing on the NMC register and passport

    Type Your Full Address, City , Postcode




    I Confirm I am eligible to work In the UK on the following basis:

    Are you an EEA National/ Citizen?
    What type of Visa/ Documentation do you hold to support your eligibility to work in the UK?


    I Confirm I am eligible to work In the UK on the following basis:

    Have you been or are you currently subject to any fitness to practise proceedings by an appropriate licensing or regulatory body in the UK or any other country?

    If Yes, please provide information on a separate sheet detailing the nature of the proceedings undertaken, or contemplated, including approximate date of proceedings, country where proceedings were undertaken and the name and address of the licensing or regulatory body concerned.


    Please submit your full Employment/Education history via a copy of your current CV.

    Your CV upload here



    Have you been convicted of a criminal offence, been bound over or cautioned or are you currently the subject of any police investigations, which might lead to a conviction, an order binding you over or a caution in the UK or any other country?

    If yes, please provide outline on a separate sheet the criminal offence, order binding you over, a caution, including approximate date, the offence and the authority and country which dealt with the offence.


    All public and private organisations request that an Enhanced Disclosure be obtained for all healthcare personnel acquired from the Disclosure and Barring Service or Disclosure Scotland through Brit Locums.

    Do you have an Enhanced Disclosure and Barring Service certificate:
    Update service


    Working Time Directive
    The Working Time Regulations 1998 require Brit Locums to limit your average weekly working time to 48 hours unless you agree with Brit Locums that the limit shall not apply to you:

    I agree to limit my working week to no more than 48 hours


    Do you suffer from any medical illness which could affect your work?
    Do you have difficulty seeing (with glasses or contact lenses if needed) for all normal work purposes?
    Do you currently take any prescribed medicines?
    Have you ever been told that you suffer from a work related health problem?
    Do you suffer from a frequent health problem that causes you to be off-sick from work more than 2-3 times a year?
    Have you ever had to give up any previous job for medical reasons?
    Have you ever had Chicken Pox?


    Not Vaccinated
    Vaccination Date
    Vaccination Administered by

    Important COVID19 Declaration

    Are you showing any COVID 19 symptoms?
    Have you, in the last 7 days been in immediate contact with anyone who is proven to have COVID19?
    Have you been on any trips outside of the UK and returned within the last few weeks? Or from 1st March?
    Do you have any underlying health conditions that might affect the work you could undertake?

    I can confirm that I have read this document fully and that all the information provided to Brit Locums is correct and to the best of my knowledge and belief.
    I give consent to contact referees regarding the information I have provided unless specified otherwise.
    I will inform Brit Locums should anything change that might affect my position and I understand the information given on this form will be processed by computer and used for registration purposes, under the Data Protection Act 1998.
    1. I understand that if I am at any stage charged or cautioned after signing this declaration, I must inform Brit Locums
    3. I am not aware of any condition, medical or otherwise, which would affect or limit my employment or performance, other than those declared in my Occupational Health Form.
    4. I acknowledge and confirm that Brit Locums is authorised to apply for and obtain a Disclosure and Barring
    Service (DBS) check and references from any previous employers and educational establishments.
    5. I declare that the information given herein is true and complete and is not presented in a way intended to mislead. I agree that if I have given false or misleading information or omit to give relevant information now or in the future that Brit Locums may cease to offer me further agency placements without notice, as well as claim for recovery of
    any payments I have received, together with a claim for loss of profit to Brit Locums.
    6. I agree that the maximum weekly working time specifiedinRegulation4(1) and (2) of the Working Time Regulations 1998 shall not apply to working with Brit Locums unless specified above.
    7. I acknowledge that my personal details will be stored and handled correctly by Brit Locums in accordance
    with the Data Protection Act 1998, however, I agree that they may be made available for audit/review by relevant third parties. (This is relevant for all information including all documents - DBS, Occupational Health, References).
    8. I understand that if I am on a student visa, I can only work for 20 hours per week during term time. I understand that I have a responsibility to monitor this. In addition, if my position as a student changes, I must inform Brit Locums.
    9. I understand that if I am on a Tier 2 Sponsorship Visa, I can only work for a maximum of 20 hours per week at the same
    professional level as my sponsorship. I understand that I have a responsibility to monitor this. In addition, if my position with my sponsored company changes, I must inform Brit Locums.
    10. I acknowledge that if any of my details stated on this Application Form change, or my circumstances change, which may affect my ability to work for Brit Locums, I must inform Brit Locums immediately.
    11. I confirm that I am not currently under investigation, or currently suspended, by my professional regulatory body or being investigated by my current or previous employer. I will Brit Locums if I am under investigation or suspended by my professional regulatory body or employer at any point while working for Brit Locums.
    12. I confirm that when asked about my working history (primarily, but not exclusively, for the purpose of the Agency Workers Regulations) I will provide accurate information.
    13. I acknowledge that should I reach the 12-week Qualifying Period under the Agency Workers Regulations, I may be asked for, and will provide, further documentation as evidence of qualifying weeks, if Brit Locums deem it necessary.
    14. I acknowledge that I have received and read through the Brit Locums Limited candidate handbook. I will abide and comply with all procedures stated

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