National Performers Lists Application Form Page 21
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32SECTION 7: Declarations – The NHS (Performers Lists) (England)
Regulations 2013
In accordance with regulation 4, sub-paragraph 5 of the NHS (Performers Lists)
(England) Regulations 2013 performers are required to make a declaration with their
application.
If you answer yes against any of the statements below performers must provide an
explanation of the facts giving rise to that matter, including those concerned, relevant
dates and any outcome. Please note that answering ‘yes’ to one or more of these
questions does not automatically preclude an applicant from being included in the
national performers list(s) or being included in the national performers lists with
conditions.
The Rehabilitation of Offenders Act 1974 and The Rehabilitation of Offenders Act 1974
(Exceptions) Order 1975 (Amendment) (England and Wales) Order 2013 do not apply
for the purpose of this declaration. Offences considered “spent” under that Act must be
declared.
Please complete the declaration below:
Yes
No
a) Do you have a criminal conviction in the United Kingdom,
including one in respect of which you have been bound over
(b) Have you ever accepted a police caution in the United Kingdom
(c) Have you ever accepted a conditional offer under section 302 of
the Criminal Procedure (Scotland) Act 1995(c) (fixed penalty:
conditional offer by procurator fiscal) or a compensation offer under
section 302A of that Act(d) (compensation offer by procurator fiscal)
or agreed to pay a penalty under section 115A of the Social Security
Administration Act 1992(a) (penalty as alternative to prosecution)
(d) Are you, in proceedings in Scotland for an offence, been the
subject of an order under section 246(2) or (3) of the Criminal
Procedure (Scotland) Act 1995 (admonition and absolute
discharge)(b) discharging you absolutely
(e) Have you been convicted elsewhere of an offence which would
constitute a criminal offence if committed in England and Wales
(f) Are you currently the subject of any proceedings (which includes
arrest, charge or bail) which might lead to a conviction
NPL1 Application Form v2 final
Page 21 of 32
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