{"id":2236,"date":"2024-05-13T05:45:40","date_gmt":"2024-05-13T05:45:40","guid":{"rendered":"https:\/\/remitystaffing.cumulative-projects.com\/?page_id=2236"},"modified":"2024-09-03T11:47:31","modified_gmt":"2024-09-03T11:47:31","slug":"remity-staffing-doctors-application-form","status":"publish","type":"page","link":"https:\/\/www.remitystaffing.com\/india\/remity-staffing-doctors-application-form\/","title":{"rendered":"Remity Staffing &#8211; Doctor&#8217;s Application Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"2236\" class=\"elementor elementor-2236\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1337320 e-flex e-con-boxed e-con e-parent\" data-id=\"1337320\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-8c47842 e-con-full e-flex e-con e-child\" data-id=\"8c47842\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6020073 elementor-widget elementor-widget-heading\" data-id=\"6020073\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Remity Staffing - Doctor's Application Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-d6ed0c3 e-flex e-con-boxed e-con e-parent\" data-id=\"d6ed0c3\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-d91fcb1 e-flex e-con-boxed e-con e-child\" data-id=\"d91fcb1\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-9906421 elementor-widget elementor-widget-heading\" data-id=\"9906421\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Remity Staffing - Doctor's Application Form<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6ece17a elementor-widget elementor-widget-shortcode\" data-id=\"6ece17a\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2238-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"2238\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/india\/wp-json\/wp\/v2\/pages\/2236#wpcf7-f2238-o1\" method=\"post\" class=\"wpcf7-form init cf7skins cf7s-default\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"2238\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2238-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:2238,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;group-37&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-doc_signature&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Type&quot;}]},{&quot;then_field&quot;:&quot;group-834&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-locum_signed&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Type&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false,&quot;notice_dismissed_rollback-cf7-5.9.3&quot;:true,&quot;notice_dismissed_rollback-cf7-5.9.5&quot;:true}}\" \/>\n<\/div>\n<style>.uacf7-prev, .uacf7-next, .wpcf7-submit{padding-top:px !important; padding-bottom:px !important; padding-left:px !important;  padding-right:px !important;}  <\/style>\t\t\t\t\t<div class=\"uacf7-steps steps-form\" style=\"display:none\">\n\t\t\t\t\t\t<div class=\"steps-row setup-panel\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"steps-step\">\n\t\t\t\t\t\t\t\t\t<a title-id=\".step-1\"\n\t\t\t\t\t\t\t\t\t\tdata-form-id=\"2238\"\n\t\t\t\t\t\t\t\t\t\thref=\"#2238step-1\"\n\t\t\t\t\t\t\t\t\t\ttype=\"button\">\n\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"steps-step\">\n\t\t\t\t\t\t\t\t\t<a title-id=\".step-2\"\n\t\t\t\t\t\t\t\t\t\tdata-form-id=\"2238\"\n\t\t\t\t\t\t\t\t\t\thref=\"#2238step-2\"\n\t\t\t\t\t\t\t\t\t\ttype=\"button\">\n\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t\t<style>\n\t\t.steps-form .steps-row .steps-step .btn-circle {\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t}\n\n\t\t.steps-form .steps-row .steps-step .btn-circle img {\n\t\t\tborder-radius: px !important;\t\t}\n\n\t\t.steps-form .steps-row .steps-step .btn-circle.uacf7-btn-active,\n\t\t.steps-form .steps-row .steps-step .btn-circle:hover,\n\t\t.steps-form .steps-row .steps-step .btn-circle:focus,\n\t\t.steps-form .steps-row .steps-step .btn-circle:active {\n\t\t\t\t\t\t\t\t}\n\n\t\t.steps-form .steps-row .steps-step p {\n\t\t\t\t\t}\n\n\t\t.steps-form .steps-row::before {\n\t\t\t\t\t}\n\n\t\t\t<\/style>\n\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"uacf7-steps steps-form \">\n\t\t\t\t\t\t\t<div class=\"steps-row setup-panel\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<div class=\"steps-step\">\n\t\t\t\t\t\t\t\t\t\t<a title-id=\".step-1\"\n\t\t\t\t\t\t\t\t\t\t\tdata-form-id=\"2238\"\n\t\t\t\t\t\t\t\t\t\t\thref=\"#2238step-1\" type=\"button\"\n\t\t\t\t\t\t\t\t\t\t\tclass=\"btn uacf7-btn-active btn-circle\">1\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t\t<div class=\"steps-info\">\n\t\t\t\t\t\t\t\t\t\t\t<p>Step 1<\/p>\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<div class=\"steps-step\">\n\t\t\t\t\t\t\t\t\t\t<a title-id=\".step-2\"\n\t\t\t\t\t\t\t\t\t\t\tdata-form-id=\"2238\"\n\t\t\t\t\t\t\t\t\t\t\thref=\"#2238step-2\" type=\"button\"\n\t\t\t\t\t\t\t\t\t\t\tclass=\"btn uacf7-btn-default btn-circle\">2\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t\t<div class=\"steps-info\">\n\t\t\t\t\t\t\t\t\t\t\t<p>Step 2<\/p>\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"uacf7-multisetp-form\">\n\t\t\t\t\t<div class=\"uacf7-form-2238  \">\t\t<div class=\"uacf7-step uacf7-step-2238 step-content\"\n\t\t\tnext-btn-text=\"\" prev-btn-text=\"\">\n\t\t\t\n<div class=\"formbox\">\n  <div class=\"row\">\n    <div class=\"col-half\">\n      <label>Title<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"title\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"title\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Forename<span class=\"required\">*<\/span> <\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"forename\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"forename\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Surname<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"surname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"surname\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Gender<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"gender\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"gender\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Current Address<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" name=\"address\"><\/textarea><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label> Postal\/ Permanent Address (as logged with GMC Register)<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"permanent_address\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"permanent_address\"><\/textarea><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Current Post Code<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"post_code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"post_code\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label> Registered Post Code<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"registered_code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"registered_code\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Tel No<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"tel_no\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"tel_no\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Email<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Date of Birth<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"dob\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dob\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>NI Number<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"ni_number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ni_number\" \/><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <label>Next of Kin<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"kin\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"kin\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Contact No<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"contact_no\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"contact_no\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Relationship<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"relationship\" \/><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <h3>Availability and Specialty<\/h3>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Grade<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"grade\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"grade\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Specialty<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"specialty\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"specialty\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Full Time<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"full_time\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"full_time\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label> Part Time <\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"part_time\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"part_time\" \/><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <label>Please give brief details of your planned career path in coming 5 years<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"plan_career\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"plan_career\"><\/textarea><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <div class=\"radio_checkbox\">\n        <label>\n          Are you on the Specialist Register? If yes, I declare that I have made formal arrangements to be appraised regularly by a Medical Practitioner entered onto the Specialist Register and enclose a copy of my Letter of Entry.\n        <\/label>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"specialist_register\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"specialist_register\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"specialist_register\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n      <\/div>\n    <\/div>\n    <div class=\"col-full\">\n      <label>GMC Number<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"gmc_num\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"gmc_num\" \/><\/span>\n    <\/div>\n  <\/div>\n<\/div>\n\t\t\t<p class=\"uacf7-buttons\">\n\t\t\t\t<button class=\"uacf7-prev\"\n\t\t\t\t\tdata-form-id=\"2238\">Previous<\/button>\n\t\t\t\t<button class=\"uacf7-next\"\n\t\t\t\t\tdata-form-id=\"2238\">Next<\/button>\n\t\t\t\t<span class=\"wpcf7-spinner uacf7-ajax-loader\"><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t \t\t<div class=\"uacf7-step uacf7-step-2238 step-content\"\n\t\t\tnext-btn-text=\"\" prev-btn-text=\"\">\n\t\t\t\n<div class=\"formbox\">\n  <div class=\"row\">\n\t\t\t<div class=\"col-half\">\n      <label>Name of Bank<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"bank_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"bank_name\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>A\/C Holder name<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"ac_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ac_name\" \/><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <label>Bank Address<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"bank_address\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"bank_address\"><\/textarea><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Account Number<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"acc_num\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"acc_num\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Sort Code<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"sort_code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"sort_code\" \/><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <h6 class=\"mb-4\"> Qualifications Please provide details of qualifications (please enclose copy certificates)<\/h6>\n    <\/div>\n    <div class=\"col-full\">\n      <label>Basic<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"basic\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"basic\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Date<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"qualify_date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date form-control\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"qualify_date\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Country<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"country\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"country\" \/><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <label>Higher <\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"higher\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"higher\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Date<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"higer_date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date form-control\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"higer_date\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Country<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"higer_country\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"higer_country\" \/><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <h6 class=\"mb-4\">Appraisals - As required by the NHS, please detail below the formalarrangements you have made to be regularly appraised by a medical practitioner entered in the Specialist Register, in the case of general Practitioners the appraiser must be (or qualified to  be) a GP Principal.<\/h6>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Name of Appraiser<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"appariser_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"appariser_name\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Date of appraisal<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"doa\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"doa\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label> Hospital\/Practice where took place<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"hospital_practice\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hospital_practice\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>GMC No. of the Appraiser<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"gmc_no\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"gmc_no\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Date of Next Appraisal<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"next_appraisal\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"next_appraisal\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Date of Revalidation<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"date_revalidation\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date_revalidation\" \/><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <h6 class=\"mb-4\">Professional Development (Annual Mandatory Trainings)<\/h6>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Mandatory Training YES\/NO (If yes give date)<span class=\"required\">*<\/span> <br \/><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"training\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"training\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>ALS \/ ATLS \/ APLS Please specify If you have any, please specify date)<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"als_atls_apls\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"als_atls_apls\" \/><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <h6 class=\"mb-4\"> Referees - Please provide details the referees covering employment History of last 3 Years<\/h6>\n    <\/div>\n    <div class=\"col-half\">\n      <label>(Ref1) Name<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_name_1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ref_name_1\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>(Ref1) E-mail<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_email_1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ref_email_1\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>(Ref1) Specialty<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_specialty_1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ref_specialty_1\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>(Ref1) Grade<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_grade_1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ref_grade_1\" \/><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <div class=\"col-half\">\n        <label>(Ref1) Hospital<\/label>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_hospital_1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ref_hospital_1\" \/><\/span>\n      <\/div>\n    <\/div>\n    <div class=\"col-half\">\n      <label>(Ref2) Name<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_name_2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ref_name_2\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>(Ref2) E-mail<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_email_2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ref_email_2\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>(Ref2) Specialty<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_specialty_2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ref_specialty_2\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>(Ref2) Grade<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_grade_2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ref_grade_2\" \/><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <div class=\"col-half\">\n        <label>(Ref2) Hospital<\/label>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_hospital_2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ref_hospital_2\" \/><\/span>\n      <\/div>\n    <\/div>\n    <div class=\"col-half\">\n      <label>(Ref3) Name<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_name_3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ref_name_3\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>(Ref3) E-mail<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_email_3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ref_email_3\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>(Ref3) Specialty<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_specialty_3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ref_specialty_3\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>(Ref3) Grade<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_grade_3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ref_grade_3\" \/><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <div class=\"col-half\">\n        <label>(Ref3) Hospital<\/label>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_hospital_3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ref_hospital_3\" \/><\/span>\n      <\/div>\n    <\/div>\n    <div class=\"col-full\">\n      <h6 class=\"mb-4\">Criminal Convictions \/ Fitness to Practice PLEASE ANSWER YES \/ NO<\/h6>\n    <\/div>\n    <div class=\"col-full\">\n      <div class=\"radio_checkbox\">\n        <label> Have you been convicted of a criminal offence, been bound over or cautioned, or are you currently the subject of a practice investigation, which might lead to a conviction, an order binding you over, or a conviction in the UK or any other country? <\/label>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"criminal_offence\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"criminal_offence\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"criminal_offence\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n      <\/div>\n    <\/div>\n    <div class=\"col-full\">\n      <h6 class=\"mb-4\">If yes, please provide details of the criminal offence, the order binding you over, the caution or details of any current proceedings which might lead to a criminal conviction, including approximate date, the offence and the authority and country that dealt with the  offence. If applicable, include details of \u2018Spent Convictions\u201d in a separate envelope addressed to The Manager marked \u2019Private and  Confidential\u2019 <\/h6>\n    <\/div>\n    <div class=\"col-full\">\n      <label>NOTE: Applicants for posts in the NHS are exempt from the Rehabilitation of Offenders Act 1974.<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"note\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"note\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <div class=\"radio_checkbox\">\n        <label> Have you been, or currently been the subject to any \u2018Fitness to Practice\u2019 proceedings by an appropriate licensing or regulatory body in the UK or any other country?<\/label>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"fitness_practice\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"fitness_practice\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"fitness_practice\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n      <\/div>\n    <\/div>\n    <div class=\"col-half\">\n      <div class=\"radio_checkbox\">\n        <label>Have you been suspended from duty with any organization or with the GMC?<\/label>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"suspended_gmc\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"suspended_gmc\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"suspended_gmc\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n      <\/div>\n    <\/div>\n    <div class=\"col-full\">\n      <h6 class=\"mb-4\"> If you have answered YES, to either of the above, please provide details of the nature of the proceedings undertaken, or contemplated, including approximate date of the proceedings, country where proceedings were undertaken and the name and address of the  licensing or regulatory body concerned.<\/h6>\n      <h6 class=\"mb-4\"> I declare that, if in the future, I am convicted of a criminal offence, bound over, or cautioned, under investigation by the GMC, the subject to \u2018Fitness to Practice\u2019 proceedings, or suspended from duty by any other employer or agency, I will inform Remity Staffing immediately.<\/h6>\n    <\/div>\n    <div class=\"col-half\">\n      <div class=\"formgroup sing\">\n        <label>Signed<span class=\"required\">*<\/span><\/label>\n        <div class=\"dscf7_signature\">\n\t\t\t<div class=\"dscf7_signature_inner\">\n\t\t\t\t<canvas id=\"digital_signature-pad_locum_signed\" name=\"locum_signed\" class=\"digital_signature-pad\" color=\"#000000\" backcolor=\"#FAFAFA\" width=\"460\" height=\"200\"><\/canvas>\n\t\t\t\t<input class=\"clearButton\" type=\"button\" value=\"+\">\n\t\t\t<\/div>\n\t\t\t<span class=\"wpcf7-form-control-wrap locum_signed\">\n\t\t\t\t<input class=\"wpcf7-form-control wpcf7-signature wpcf7-validates-as-requiredwpcf7-validates-as-signature form-controldscf7-signature\" value=\"\" type=\"hidden\" name=\"locum_signed\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"locum_signed-attachment\" class=\"wpcf7_input_locum_signed_attachment\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"locum_signed-inline\" class=\"wpcf7_input_locum_signed_inline\"\/>\n\t\t\t<\/span>\n\t\t<\/div>\n        <div class=\"radio_checkbox\">\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"radio-locum_signed\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-locum_signed\" value=\"Draw\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Draw<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-locum_signed\" value=\"Type\" \/><span class=\"wpcf7-list-item-label\">Type<\/span><\/label><\/span><\/span><\/span>\n        <\/div>\n        <span data-id=\"group-834\" data-orig_data_id=\"group-834\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n        <input\n          type=\"text\"\n          name=\"sign_text form-control\"\n          id=\"sign_text\"\n          oninput=\"changeFont(this,'digital_signature-pad_locum_signed')\"\n        \/>\n        <\/span>\n      <\/div>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Date<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"locum_signed_date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"locum_signed_date\" \/><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <h6 class=\"mb-4\">Right to Work in the UK<\/h6>\n    <\/div>\n    <div class=\"col-half\">\n      <label>What is your right to work in the UK? (lease tick appropriate)<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"right_towork\"><select class=\"wpcf7-form-control wpcf7-select form-control\" aria-invalid=\"false\" name=\"right_towork\"><option value=\"EU Citizen\">EU Citizen<\/option><option value=\"Spouse of EU Citizen\">Spouse of EU Citizen<\/option><option value=\"Right of Abode in the UK\">Right of Abode in the UK<\/option><option value=\"Admitted in UK as a Doctor before 1 April 1985\">Admitted in UK as a Doctor before 1 April 1985<\/option><option value=\"Work Permit\">Work Permit<\/option><option value=\"Student Visa\">Student Visa<\/option><option value=\"British Citizen\">British Citizen<\/option><\/select><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Work Perm, Student Visa or HSMP Visa Expiry Date<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"visa_date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date form-control\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"visa_date\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Nationality<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"nationality\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nationality\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Expiry Date<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"expiry_date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date form-control\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"expiry_date\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Professional Indemnity<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"prof_indemnity\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"prof_indemnity\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Defense Body Name<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"defense_body\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"defense_body\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Policy Number<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"policy_num\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"policy_num\" \/><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <h6 class=\"mb-4\">COVID-19 & Flu Vaccination Declarations<\/h6>\n      <p> Under the current guidelines, every healthcare worker need to have annual flu vaccination and also at-least 2 jabs of COVID-19  Vaccination to work within NHS.<\/p>\n    <\/div>\n    <div class=\"col-full\">\n      <label>Did you receive Flu vaccination within last 12 months? If yes, please supply the date. If no please explain why.<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"flu_vaccine\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"flu_vaccine\" \/><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <h6 class=\"mb-4\">Did you have your both COVID-19 Jab now? If Yes please supply the dates. If no please explain why and also when you going to have these.<\/h6>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Date of First Covid-19 Jab<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"date_first\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date form-control\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date_first\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Date of 2nd Jab<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"date_second\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date form-control\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date_second\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Please explain here, why you have not had your COVID-19 Jabs<\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"no_jabs\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date form-control\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"no_jabs\" \/><\/span>\n    <\/div>\n    <div class=\"col-full\">\n      <h6 class=\"mb-4\">Doctors Declaration - Please note that Remity Staffing may at its discretion change the format and wording of any CV provided by you to put in a form that is acceptable to trusts and hospitals. If you do not agree to Remity Staffing altering your CV in this way, please tick [ ] Please read the following statements and sign if you agree to all. 1. I understand I will be asked to sign a form declaring my good health and GMC Status at the start of every assignment 2. I agree for all my details, within the registration pack to be shared with approved third parties i.e Auditors and NHS clients. 3. I am willing for Remity Staffing to apply for a Criminal Records Bureau for \u201cDisclosure\u201d and, if requested, forward confirmation of such to any hospital where I may be assigned. 4. I will comply with the Department of Health guidelines; HIV\/AIDS; MRSA; HEP \u2018B\u2019\/\u2019C\u2019 (HSC 2000\/20) 5. I will comply with all NHS regulations currently in place including regular health screening: data protection compliance\/confidentiality, discrimination law and Health and Safety at Work Act 1974 6. I will act only on the instruction\/direction of authorised\/appropriate NHS trust\/Health Authority personnel 7. I am willing, at the request of NHS trust, to work over Working Time Regulation guidelines and I agree to opt out of Regulation 5 of the Working Time Regulations 1998 8. I have received, read and understand the guidance in the Remity Staffing handbook and will fully comply with its requirements 9. I accept and will abide fully by the Terms of Engagement of Remity Staffing outlined in handbook 10. I will notify NISI\n        Staffing IMMEDIATELY of changes to the above information 11. I confirm that I have received Remity Staffing\u2019s agency ID Badge 12. I enclose a completed pre-employment health questionnaire and equal opportunities form 13. I declare that I will keep Remity Staffing informed of all the necessary arrangements to remain on the GMC License to Practice Register: 14. I declare that the information provided above is true and correct<\/h6>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Print full Name<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"print_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"print_name\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <label>DOB<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"dob_2\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dob_2\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\">\n      <div class=\"formgroup sing\">\n        <label>Signature<span class=\"required\">*<\/span><\/label>\n        <div class=\"dscf7_signature\">\n\t\t\t<div class=\"dscf7_signature_inner\">\n\t\t\t\t<canvas id=\"digital_signature-pad_doc_signature\" name=\"doc_signature\" class=\"digital_signature-pad\" color=\"#000000\" backcolor=\"#FAFAFA\" width=\"460\" height=\"200\"><\/canvas>\n\t\t\t\t<input class=\"clearButton\" type=\"button\" value=\"+\">\n\t\t\t<\/div>\n\t\t\t<span class=\"wpcf7-form-control-wrap doc_signature\">\n\t\t\t\t<input class=\"wpcf7-form-control wpcf7-signature wpcf7-validates-as-requiredwpcf7-validates-as-signature form-controldscf7-signature\" value=\"\" type=\"hidden\" name=\"doc_signature\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"doc_signature-attachment\" class=\"wpcf7_input_doc_signature_attachment\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"doc_signature-inline\" class=\"wpcf7_input_doc_signature_inline\"\/>\n\t\t\t<\/span>\n\t\t<\/div>\n        <div class=\"radio_checkbox\">\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"radio-doc_signature\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-doc_signature\" value=\"Draw\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Draw<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-doc_signature\" value=\"Type\" \/><span class=\"wpcf7-list-item-label\">Type<\/span><\/label><\/span><\/span><\/span>\n        <\/div>\n        <span data-id=\"group-37\" data-orig_data_id=\"group-37\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n        <input\n          type=\"text\"\n          name=\"sign_text form-control\"\n          id=\"sign_text\"\n          oninput=\"changeFont(this,'digital_signature-pad_doc_signature')\"\n        \/>\n        <\/span>\n      <\/div>\n    <\/div>\n    <div class=\"col-half\">\n      <label>Date<span class=\"required\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"doc_date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"doc_date\" \/><\/span>\n    <\/div>\n    <div class=\"col-half\"><input class=\"wpcf7-form-control wpcf7-submit has-spinner submit_button\" type=\"submit\" value=\"Submit\" \/><\/div>\n  <\/div>\n<\/div>\n\t\t\t<p class=\"uacf7-buttons\">\n\t\t\t\t<button class=\"uacf7-prev\"\n\t\t\t\t\tdata-form-id=\"2238\">Previous<\/button>\n\t\t\t\t<button class=\"uacf7-next\"\n\t\t\t\t\tdata-form-id=\"2238\">Next<\/button>\n\t\t\t\t<span class=\"wpcf7-spinner uacf7-ajax-loader\"><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<\/div>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Remity Staffing &#8211; 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