Application Form

Name should be in FULL, as appearing on HCPC/ NMC/ NISCC Registration and Passport

If you have lived less than 5 years at above address, please fill in the fields below

Please ensure you provide details of all previous employment starting with the most recent first. Include any gaps in employment and reasons for those gaps since leaving full time education.

This record should include all your work history. Please use the continuation sheet provided

Please give the names of the Two Professional Referees (From your 2 most recent engagements). Referees must be your line Manager or a band Higher than you.

The Working Time Regulations 1998 (“The Regulation”) require SOS Medical also trading as SOS Medical Staffing to limit your average weekly working time unless you agree with SOS Medical that the limit shall not apply to contract with us. The 48 hr time limit will not apply to you

Either party may terminate the agreement (so that the time limit will apply to you) by giving the person at SOS Medical to whom you usually report 4 weeks written notice. unless it is terminated in this way, this agreement shall remain in force until your contract with us terminates. Under regulation, SOS Medical must keep records relating to your working time. This is the case whether or not you reach an agreement with SOS Medical about waiving time limits.

Please sign below to confirm you agree that this time limit on your working hours will not apply to your contract with SOS Medical & that your average working week may therefore exceed 48 hours in any given period

Applicants for healthcare positions are exempt from the Rehabilitation of Offenders Act 1974. You are required to declare prosecutions or convictions, including those considered 'spent' under this Act

All public and private organisations request that an Enhanced Disclosure be obtained for all healthcare personnel which is acquired from the Criminal Records Bureau or Disclosure Scotland through SOS Medical. Copies of SOS Medical Policies on the Recruitment of Ex-Offenders and Storage & Disposal of DBS/ PVG/ ACCESS NI Disclosures are available on request.

Please provide the information below, whichever is applicable. If not applicable, please write N/A

The NHS Clinical Negligence Scheme pays only for cases of medical negligence that arise in NHS hospitals. It does not provide support in a variety of other situations, including criminal cases, NMC or disciplinary proceedings and good Samaritan acts. There are positions which you may be offered, for which Professional Indemnity is mandatory. In all cases, we strongly recommend that healthcare workers take out and maintain Medical Insurance

SOS Medical supplies to numerous hospitals across the country and do offer accommodation to the nurses that travel away from there home. This accommodation arrangement could be in different ways; i.e full accommodation or half accommodation cost paid by the agency. Below is the accommodation policy and the terms:

1. If the agency has agreed to cover the full accommodation cost, this will only be applicable where the nurse works a minimum of 5 shifts per week for them to be entitled to free accommodation.

2. Should the nurse work less than 5 days per week, and the agency has paid for the whole week, then the nurse agrees for the agency to deduct the cost of accommodation for the days she didn’t stay or work from her pay.

3. In the event, if the nurse has agreed to do the shifts and the agency has paid for the accommodation but later the nurse decided to cancel her travel due to any reason, then the nurse will be liable to pay the accommodation cost to the agency. The agency will try to get a refund from the Landlord and in the event the agency couldn’t get the money back, then the nurse agrees for the agency to deduct this money from her next pay. In the event, there is no timesheets submitted, the nurse will pay the agency via BACS transfer.

4. The agency pays the Landlord a month in advance whereas the accommodation cost is only deducted a week in arrears from the nurse. In the even the nurse decides to leave the accommodation earlier than the month ends, then the nurse will be liable to pay for the rest of the month and this will be deducted from the nurses last pay.

1. I confirm that I have read this document fully and that all the information given to SOS Medical Ltd is correct to the best of my knowledge and belief. I understand that a false declaration may lead to refusal of this application. If, while I am working with SOS Medical Ltd or any of its associated companies, any of the information provided changes, I agree to notify SOS Medical Ltd in writing immediately.

2. I understand and agree to SOS Medical Ltd disclosing this information to their clients and also use my information within the group of companies with SOS Medical for the purpose of finding me assignments. I have read, understood and accept the information contained within the Staff Handbook I have read and agree to adhere to the SOS Medical Ltd Terms of Engagement.

3. I understand that if I am charged or cautioned after signing this declaration, I must inform SOS Medical

4. I acknowledge that I have been given a copy of the Terms and Conditions of Service issued by SOS Medical, which is mine to keep, and furthermore that I have read those Terms and Conditions and agree to abide by them.

5. 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 Questionnaire.

6. 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 SOS Medical may cease to offer me further agency placements without notice, as well as a claim for recovery of any payments I have received, together with a claim for a loss of profit to SOS Medical.

7. I acknowledge and confirm that SOS Medical is authorised to apply for and obtain a Disclosure and Barring Service Check (including the online status update service check if app) and references from any previous employers and educational establishments. I will pay the cost for any Disclosure services and can be deducted from my Salary if need be.

8. I acknowledge that my personal details will be stored and handled correctly by SOS Medical 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).

9. 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 SOS Medical.

10. 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 SOS Medical.

11. I understand that if it is pre-authorised that my travel expenses will be reimbursed outside of the SOS Medical Payment scheme, I cannot make a duplicate claim under the SOS Medical Payment Scheme and that any attempt to do so will be treated seriously.

12. 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 SOS Medical, I must inform SOS Medical immediately.

13. I confirm that I am not currently under investigation, or currently suspended, by my professional regulatory body (e.g. NMC, GMC) or being investigated by my current or previous employer. I will inform SOS Medical if I am under investigation or suspended by my professional regulatory body or employer at any point whilst working for SOS Medical.

14. I confirm that when asked about my working history (primarily, but not exclusively, for the purposes of the Agency Workers Regulations) I will provide accurate information.

15. 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 SOS Medical deems it necessary.

16. I give my permission for SOS Medical to run a Right to Work check with the Home Office if I provide them a Biometric Residence Card for my Right to work in the UK.