Please complete our online registration form to register with Bluestones Medical. Name Personal details Salutation How do you want to be known? Mr Mrs Ms Miss Dr Other First name Surname Known as * Date of birth Gender Male Female Other NI number * Your phone number * Your email address * Your address * Your job title RGN ODP RMN RNLD Midwife HCA Support Worker Other Next of kin * Relationship * Spouse Partner Parent Guardian Children Sibling Other Next of kin's contact number * Upload a copy of your CV and any associated documentation Add files Supported file types: doc, docx, rtf, txt, pdf, jpg Right to work Are you legally eligible to work in the UK? * Yes No Are you required to have a UK work visa/permit? * Yes No Professional Registration Issuing body PIN number Have you ever been investigated, removed or suspended by the NMC / HCPC? Yes No Rehabilitation of Offenders Act Have you ever been convicted, cautioned, reprimanded or given a final warning for a criminal offence? * Yes No Are you waiting to hear about any prosecutions pending? * Yes No Are you aware of any police enquiries undertaken following allegations made against you, which may have a bearing on your suitability? * Yes No Have you ever been the subject of a disciplinary investigation or proceedings by a previous employer in any position you have held? * Yes No Consent Please confirm that you consent to the following by ticking each statement. You must consent to each of these statements in order for us to process your registration. Consent to 3rd party audit checks I consent Consent for Bluestones Medical to apply for a DBS, for DBS update service checks and retention of a copy of your DBS certificate I consent Consent for my personal data to be supplied to your preferred umbrella company (if applicable) I consent Consent to approach references I consent Consent to Right to Work checks I consent Consent to Professional Regulatory Body Checks I consent Consent for Bluestones Medical to provide copies of my CV, DBS and references to any prospective employer for the purposes of securing work I consent References Please provide details of two references. These must cover at least 3 years of your most recent employment history. Reference 1: Name Reference 1: Position Reference 1: Organisation Reference 1: Contact number Reference 1: Email address Reference 2: Name Reference 2: Position Reference 2: Organisation Reference 2: Contact number Reference 2: Email address How did you hear about Bluestones Medical? Colleague referral Job board LinkedIn Facebook Press advert Event / exhibition Search engine (eg Google) Other Declaration I hereby confirm that the information given within this form is as complete as possible, true and correct and states that I am entitled to work through an agency in the UK. I agree that I will comply with all compliance procedures and ensure that all my documentation is present and correct. I understand that appointment to any position is conditional on satisfactory registration and qualification checks, and that any information disclosed on this registration form will be checked. Any offer of appointment may be withdrawn if you knowingly withhold information, or provide false or misleading information, and that registration may be terminated should any subsequent information come to light once you have been appointed. The WTR place a limit on the average number of hours per week that can be worked. If you are prepared to work more than the stipulated average hours per week (48 hrs) and therefore opt out of the WTR agreement, please complete your registration by submitting this form.