Gp Job Application Form (Page 3 of 3) in pdf

Gp Job Application Form Page 3

Private & Confidential

Hallam GPs Limited

19 Neepsend Triangle Business Centre

1 Burton Road

Sheffield

S3 8BW

E-mail:

Web:

Rehabilitation of Offenders

Because of the nature of General Practice, this position is exempt from the provisions of section 4.2 of the

Rehabilitation of Offenders Act 1974 (Exemption Order 1975). You are therefore, not entitled to withhold

information about convictions which for other purposes are ‘spent’ under the provisions of the Act.

In the event of engagement, any failure to disclose any convictions will result in immediate termination of

the contract with further referral to the appropriate oversight bodies.

Any information given will be completely confidential and a criminal record will not necessarily be a bar to

obtaining a position.

Have you ever been convicted of a criminal offence? Y

Do you have any unspent convictions? Y

If yes please provide details:

Are you currently involved in any proceedings, which may lead to a criminal conviction? Y

If yes please provide details:

Are you currently suspended or under investigation with your professional registration body? (GMC etc.)

If yes please supply details…

Please note if the above changes you must make us aware as soon as possible.

I confirm all of the above details are true and correct:

Signed:

Print Name:

Date:

Bank Details

Bank:

Account Name:

Sort Code: ___ - ___ - ___

Account Number:

Registered Office: 19 Neepsend Triangle Business Centre, 1 Burton Road, Sheffield, S3 8BW

Registered in England No. 8391471

Gp Job Application Form Page 3