Registration Online Form Only for the UKPERSONAL DETAILSProfession *Sex *MaleFemaleTitle Surname *Forenames *Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountryHome Phone Work Phone Mobile Phone Email *Do you monitor your email frequently? *YesNoWould you like us to use email as our normal means of contact for general news? *YesNoWould you like to be added to our email newsletter? *YesNoNational Insurance Number *P45 Enclosed? *YesNoNEXT OF KIN DETAILSTitle First Names Surname Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountryContact Number PROOF OF IDENTITY In line with UKBA guidance on the prevention of illegal working we will need to verify and take copies of your original ID documentation as evidence of your right to work in the UK if you are to be engaged by Sonographers Medical for temporary workNationality *Are you a British Citizen / E C National? *YesNoIf no, what is the nature of your Right to Work in the UK? Are there restrictions on your passport / visa limiting your Right to Work in the UK? *YesNoAre you subject to Work Permit Provisions? *YesNo If you do not understand the questions given above, explain why you have a Right to Work in the UK and supply copies of any relevant paperwork.PROFESSIONAL EXPERIENCE Most recent firstCurrent or Last Employer, Name & Address Grade / Dept Clinical Experience From To Reason for Leaving Current or Last Employer, Name & Address Grade / Dept Clinical Experience From To Reason for Leaving Current or Last Employer, Name & Address Grade / Dept Clinical Experience From To Reason for Leaving PROFESSIONAL QUALIFICATIONSUniversity/Institution - Qualification - Date Obtained File Upload Please submit copies of all Vocational CertificatesSTATE REGISTRATIONSHealth Professions Council - Registered Name Registered Number Valid Until Alternative State Registration - Organisation Registered Name Registered Number Valid Until PROFESSIONAL COLLEGES, SOCIETIES, UNIONSName of Organisation - Type of Membership - Number - Renewal Date UK BANK DETAILSAccount Name Account Number Sort Code Name of Bank Bank Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountryBuilding Society Roll number If relevantAVAILABILITYDate Available for Locum Work If knownIn which parts of the Country are you prepared to work? Sub-specialties in which you are prepared to work Type of Work Preferred Full TimePart TimeAnnual HolidaysAnnual HolidaysWeekendsOther If available, would you require accommodation? YesNoDo you have own Transport available & UK acceptable Driving Licence? YesNoAny additional information regarding Placements CRB DISCLOSUREDo you have any unspent* criminal convictions? **Certain types of employment and professions are exempt from the Rehabilitation of Offenders Act 1974 and in those cases particularly where the employment is sought in relation to positions involving working with children or vulnerable adults, details for all criminal convictions must be given. The information given will be treated in the strictest of confidence and only taken into account where, in the reasonable opinion of [insert company name], the offence is relevant to the post to which you are applying. Failure to declare a conviction may require us to exclude you from our register or terminate an assignment if the offence is not declared but later comes to light.YesNoIf yes, state convictions and dates HEALTH AND DISABILITY The following questions on health and disability are asked in order to find out your needs in terms of reasonable adjustments to access our recruitment service and to find out your needs in order to perform the job or position sought.Do you have any health issues or a disability relevant which may make it difficult for you to carry out functions which are essential for the role you seek? *YesNoIf yes, please specify DATA PROTECTION STATEMENT The information that you provide on this form and on any CV given will be used by Sonographers Medical to provide you work finding services. In providing this service to you, you consent to your personal data being included on a computerised database and consent to us transferring your personal details to our clients. We may check the information collected, with third parties or with other information held by us. We may also use or pass to certain third parties information to prevent or detect crime, to protect public funds, or in other way permitted or required by law.CANDIDATE DECLARATION I hereby confirm that the information given is true and correct. I consent to my personal data and CV being forwarded to clients. I consent to references being passed onto potential employers. If, during the course of a temporary assignment, the Client wishes to employ me direct, I acknowledge that Sonographers Medical will be entitled either to charge the client an introduction/transfer fee, or to agree an extension of the hiring period with the Client (after which I may be employed by the Client without further charge being applicable to the Client).Name *Date *EQUAL OPPORTUNITIES This will be detached from the application form and stored in a private confidential file.) Sonographers Medical is committed to a policy of equal opportunities for all work seekers and shall adhere to such a policy at all times and will review on an on-going basis on all aspects of recruitment to avoid unlawful or undesirable discrimination. We will treat everyone equally irrespective sex, sexual orientation, gender reassignment, marital or civil partnership status, age, disability, colour, race, nationality, ethnic or national origin, religion or belief, political beliefs or membership or non-membership of a Trade Union and we place an obligation upon all staff to respect and act in accordance with the policy. Sonographers Medical shall not discriminate unlawfully when deciding which candidate/temporary worker is submitted for a vacancy or assignment, or in any terms of employment or terms of engagement for temporary workers Sonographers Medical will ensure that each candidate is assessed only in accordance with the candidate’s merits, qualification and ability to perform the relevant duties required by the particular vacancy.Name Registered Body Number Position applied for 1) Ethnic Category The following categories are based on those used in the 2001 census as recommended by the EHRC. Please note the ethnic questions are not about nationality, place of birth or citizenship. UK citizens can belong to any of the ethnic categories indicated. Please tick the box below which best describes the ethnic category to which you belong:a) White BritishIrishAny other White background – please write in below b) Mixed – please also tick one of the boxes below White and Black CaribbeanWhite and Black AfricanWhite and AsianAny other mixed background – please write in below c) Asian or Asian British IndianPakistaniBangladeshiAny other Asian background – please write in below d) Black or Black British Black CaribbeanBlack AfricanAny other Black background – please write in below e) Chinese or Chinese British or other ethnic group ChineseAny other ethnic background – please write in below 2) Gender Please tick appropriate box MaleFemale3) Disability Please state if you have any long-term physical or mental condition that affects your ability to carry out day-to-day activities. (Advice can be obtained from the EHRC 0845 604 6610) YesNo4) Age Please state your age and date of birthAge Date of Birth 5) Religion Please state your religion VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
