{"id":2248,"date":"2024-05-13T07:26:47","date_gmt":"2024-05-13T07:26:47","guid":{"rendered":"https:\/\/remitystaffing.cumulative-projects.com\/?page_id=2248"},"modified":"2024-12-05T09:55:17","modified_gmt":"2024-12-05T09:55:17","slug":"remity-staffing-clinical-application-form","status":"publish","type":"page","link":"https:\/\/www.remitystaffing.com\/india\/remity-staffing-clinical-application-form\/","title":{"rendered":"Remity Staffing -Clinical Application Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"2248\" class=\"elementor elementor-2248\">\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 - Clinical 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 - Clinical 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-e7eaa86 elementor-widget elementor-widget-heading\" data-id=\"e7eaa86\" 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<h5 class=\"elementor-heading-title elementor-size-default\">Clinical Application Form<\/h5>\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-f2244-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"2244\">\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\/2248#wpcf7-f2244-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=\"2244\" \/>\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-f2244-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;:2244,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;group-834&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-disclosure_sign&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Type&quot;}]},{&quot;then_field&quot;:&quot;group-587&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-payment_sign&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Type&quot;}]},{&quot;then_field&quot;:&quot;group-37&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-declarations_sign&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=\"2244\"\n\t\t\t\t\t\t\t\t\t\thref=\"#2244step-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=\"2244\"\n\t\t\t\t\t\t\t\t\t\thref=\"#2244step-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\t\t<div class=\"steps-step\">\n\t\t\t\t\t\t\t\t\t<a title-id=\".step-3\"\n\t\t\t\t\t\t\t\t\t\tdata-form-id=\"2244\"\n\t\t\t\t\t\t\t\t\t\thref=\"#2244step-3\"\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-4\"\n\t\t\t\t\t\t\t\t\t\tdata-form-id=\"2244\"\n\t\t\t\t\t\t\t\t\t\thref=\"#2244step-4\"\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-5\"\n\t\t\t\t\t\t\t\t\t\tdata-form-id=\"2244\"\n\t\t\t\t\t\t\t\t\t\thref=\"#2244step-5\"\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-6\"\n\t\t\t\t\t\t\t\t\t\tdata-form-id=\"2244\"\n\t\t\t\t\t\t\t\t\t\thref=\"#2244step-6\"\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 progressbar-style-1\">\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=\"2244\"\n\t\t\t\t\t\t\t\t\t\t\thref=\"#2244step-1\" type=\"button\"\n\t\t\t\t\t\t\t\t\t\t\tclass=\"btn uacf7-btn-active btn-circle\"><p>Step 1<\/p>\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\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=\"2244\"\n\t\t\t\t\t\t\t\t\t\t\thref=\"#2244step-2\" type=\"button\"\n\t\t\t\t\t\t\t\t\t\t\tclass=\"btn uacf7-btn-default btn-circle\"><p>Step 2<\/p>\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\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-3\"\n\t\t\t\t\t\t\t\t\t\t\tdata-form-id=\"2244\"\n\t\t\t\t\t\t\t\t\t\t\thref=\"#2244step-3\" type=\"button\"\n\t\t\t\t\t\t\t\t\t\t\tclass=\"btn uacf7-btn-default btn-circle\"><p>Step 3<\/p>\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\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-4\"\n\t\t\t\t\t\t\t\t\t\t\tdata-form-id=\"2244\"\n\t\t\t\t\t\t\t\t\t\t\thref=\"#2244step-4\" type=\"button\"\n\t\t\t\t\t\t\t\t\t\t\tclass=\"btn uacf7-btn-default btn-circle\"><p>Step 4<\/p>\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\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-5\"\n\t\t\t\t\t\t\t\t\t\t\tdata-form-id=\"2244\"\n\t\t\t\t\t\t\t\t\t\t\thref=\"#2244step-5\" type=\"button\"\n\t\t\t\t\t\t\t\t\t\t\tclass=\"btn uacf7-btn-default btn-circle\"><p>Step 5<\/p>\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\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-6\"\n\t\t\t\t\t\t\t\t\t\t\tdata-form-id=\"2244\"\n\t\t\t\t\t\t\t\t\t\t\thref=\"#2244step-6\" type=\"button\"\n\t\t\t\t\t\t\t\t\t\t\tclass=\"btn uacf7-btn-default btn-circle\"><p>Step 6<\/p>\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\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-2244  \">\t\t<div class=\"uacf7-step uacf7-step-2244 step-content\"\n\t\t\tnext-btn-text=\"\" prev-btn-text=\"\">\n\t\t\t\n<div class=\"formbox\">\n\t<div class=\"row\">\n\t\t<div class=\"col-full\">\n\t\t\t<h6 class=\"mb-4\">Personal Details<\/h6>\n\t\t<\/div>\n\t\t\t<div class=\"col-half\">\n\t\t\t\t\t<label>Title<span class=\"required\">*<\/span> <\/label>\n\t\t\t\t\t<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\t\t\t<\/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> Forename(s)<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>Nationality<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"nationality\"><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=\"nationality\" \/><\/span>\n        <\/div>\n        <div class=\"col-full\">\n            <label>Contact Address<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"current_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=\"current_address\"><\/textarea><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Postcode<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"postCode\"><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=\"postCode\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>National Insurance No<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"national_insurance_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=\"national_insurance_no\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Home Phone<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"home_no\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"home_no\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Mobile Phone<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"mobile_phone\"><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=\"mobile_phone\" \/><\/span>\n\t\t\t\t<\/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            <div class=\"radio_checkbox\">\n                <label>Do you own a car<\/label>\n                <span class=\"wpcf7-form-control-wrap\" data-name=\"own_car\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"own_car\" 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=\"own_car\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n            <\/div>\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>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>Registration No<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"hpc_no\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hpc_no\" \/><\/span>\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-full\">\n            <h6 class=\"mb-4\">Professional Misconduct<\/h6>\n        <\/div>\n        <div class=\"col-half\">\n            <div class=\"radio_checkbox\">\n                <label>Have there been any proceedings of medical negligence or professional misconduct against you and\n                    have you ever been suspended<\/label>\n                <span class=\"wpcf7-form-control-wrap\" data-name=\"medical\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"medical\" 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=\"medical\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n            <\/div>\n        <\/div>\n        <div class=\"col-half\">\n            <label>If \u201cYES\u201d please supply details: <\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"yes_detail\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"yes_detail\" \/><\/span>\n        <\/div>\n        <div class=\"col-full\">\n            <h6 class=\"mb-4\">Next of Kin Details<\/h6>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Name<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"kin_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=\"kin_name\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Telephone<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"kin_tel\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"kin_tel\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Relation<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"Relation\"><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=\"Relation\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Contact Address<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"current_address_2\"><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=\"current_address_2\"><\/textarea><\/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=\"2244\">Previous<\/button>\n\t\t\t\t<button class=\"uacf7-next\"\n\t\t\t\t\tdata-form-id=\"2244\">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\n\n\t\t<div class=\"uacf7-step uacf7-step-2244 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-full\">\n            <h6 class=\"mb-4\">Immigration Status<\/h6>\n        <\/div>\n        <div class=\"col-full\">\n            <label>Your entitlement for working as a Healthcare Professional in the UK is based upon what status<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"healthcare_professional\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" name=\"healthcare_professional\"><option value=\"EU Citizen\">EU Citizen<\/option><option value=\"Spouse of an EU Citizen\">Spouse of an EU Citizen<\/option><option value=\"Work Permit (Tier 1)\">Work Permit (Tier 1)<\/option><option value=\"Tier 2 Visa\">Tier 2 Visa<\/option><option value=\"British National\">British National<\/option><option value=\"Admitted to UK Healthcare worker Prior to 1985\">Admitted to UK Healthcare worker Prior to 1985<\/option><\/select><\/span>\n        <\/div>\n        <div class=\"col-full\">\n            <label>Please provide a right to work share code to prove your immigratation status if you do not have UK\n                Passport <\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"immigratation\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immigratation\" \/><\/span>\n        <\/div>\n        <div class=\"col-full\">\n            <h6 class=\"mb-4\">Rehabilitation of Offenders Act - Because of the nature of the work for which you are\n                applying, Section 4(2), and further Orders made by the Secretary of State under the provision of this\n                section of the Rehabilitation of Offenders Act (1974) (Exceptions) Order 1975 apply. Applicants are\n                therefore required to give information about convictions which for other purposes are \u201cspent\u201d under the\n                provisions of the Act. Any information given will be completely confidential and will be considered only\n                in relation for positions to which the order applies. <\/h6>\n        <\/div>\n        <div class=\"col-half\">\n            <div class=\"radio_checkbox\">\n                <label> Have you at any time been convicted of an offence<\/label>\n                <span class=\"wpcf7-form-control-wrap\" data-name=\"time_convicted\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"time_convicted\" 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=\"time_convicted\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n            <\/div>\n        <\/div>\n        <div class=\"col-half\">\n            <label>If \u201cYes\u201d, please give details in the box provided.<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"time_yes\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"time_yes\" \/><\/span>\n        <\/div>\n        <div class=\"col-full\">\n            <h6 class=\"mb-4\"> It is a condition of proceeding with your application that we apply for an \u201cEnhanced\u201d DBS disclosure or produce a disclosure which you have already obtained. Convictions and any other criminal record information obtained through the Disclosure and Barring Service will not necessarily be a bar to employment. All circumstances will be taken into account. However, any inconsistencies compared with the information given above may invalidate your application. It is a condition of engagement that clients will be informed of details of criminal convictions so that they may make an informed decision as to whether or not to engage a candidate on a temporary assignment.<\/h6>\n        <\/div>\n        <div class=\"col-full\">\n            <h6 class=\"mb-4\"> Declaration - 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. <\/h6>\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_disclosure_sign\" name=\"disclosure_sign\" 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 disclosure_sign\">\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=\"disclosure_sign\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"disclosure_sign-attachment\" class=\"wpcf7_input_disclosure_sign_attachment\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"disclosure_sign-inline\" class=\"wpcf7_input_disclosure_sign_inline\"\/>\n\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\n                <div class=\"radio_checkbox\">\n                    <span class=\"wpcf7-form-control-wrap\" data-name=\"radio-disclosure_sign\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-disclosure_sign\" 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-disclosure_sign\" 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 type=\"text\" name=\"sign_text form-control\" id=\"sign_text\"\n                    oninput=\"changeFont(this,'digital_signature-pad_disclosure_sign')\">\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=\"disclosure_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=\"disclosure_date\" \/><\/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=\"2244\">Previous<\/button>\n\t\t\t\t<button class=\"uacf7-next\"\n\t\t\t\t\tdata-form-id=\"2244\">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\n\n\t\t<div class=\"uacf7-step uacf7-step-2244 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-full\">\n            <h6 class=\"mb-4\"> References - We require two Clinical Professional Referees. One must be from your present\n                or most recent employer and must be a senior grade to yourself. <\/h6>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Name (Ref1)<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"name_ref_1\"><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=\"name_ref_1\" \/><\/span>\n        <\/div>\n        <div class=\"col-full\">\n            <label>Position (Ref1)<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"position_ref_1\"><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=\"position_ref_1\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Work Address (Ref1)<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"work_ref_1\"><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=\"work_ref_1\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Telephone (Ref1)<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"tele_ref_1\"><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=\"tele_ref_1\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label> Email (Ref1) - must be NHS or a Business emaill address<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"email_ref_1\"><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_ref_1\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <div class=\"radio_checkbox\">\n                <label>May we contact your referee prior to an interview? (Ref1)<\/label>\n                <span class=\"wpcf7-form-control-wrap\" data-name=\"contact_refree_1\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"contact_refree_1\" 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=\"contact_refree_1\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n            <\/div>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Name (Ref2)<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"name_ref_2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"name_ref_2\" \/><\/span>\n        <\/div>\n        <div class=\"col-full\">\n            <label>Position (Ref2)<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"position_ref_2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"position_ref_2\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Work Address (Ref2)<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"work_ref_2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"work_ref_2\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Telephone (Ref2)<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"tele_ref_2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"tele_ref_2\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Email (Ref2) - must be NHS or a Business emaill address<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"email_ref_2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email form-control\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email_ref_2\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <div class=\"radio_checkbox\">\n                <label>May we contact your referee prior to an interview? (Ref2)<span class=\"required\">*<\/span><\/label>\n                <span class=\"wpcf7-form-control-wrap\" data-name=\"contact_refree_2\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"contact_refree_2\" 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=\"contact_refree_2\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n            <\/div>\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=\"2244\">Previous<\/button>\n\t\t\t\t<button class=\"uacf7-next\"\n\t\t\t\t\tdata-form-id=\"2244\">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\n\t\t<div class=\"uacf7-step uacf7-step-2244 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-full\">\n            <h6 class=\"mb-4\"> COVID-19 & Flu Vaccination Declarations<\/h6>\n            <p class=\"mb-4\">Under the current guidelines, its recommended that every healthcare worker should 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.<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"flu_vaccin\"><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=\"flu_vaccin\" \/><\/span>\n        <\/div>\n        <div class=\"col-full\">\n            <p>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.<\/p>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Date of First Jab (Covid-19)<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"dose_1\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date form-control\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dose_1\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label> Date of 2nd Jab<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"dose_2\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date form-control\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dose_2\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>If you did not receive any Jabs for Covid-19 vaccinations, please explain here why.<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"no_dose\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"no_dose\" \/><\/span>\n        <\/div>\n        <div class=\"col-full\">\n            <h6 class=\"m-4\"> Appraisal & Revalidation \u2013 (Nurses Only)<\/h6>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Last Appraisal Date<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"last_appraisal_date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date form-control\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"last_appraisal_date\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Next Appraisal Date<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"next_appraisal_date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date form-control\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"next_appraisal_date\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Name of Appraiser<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"name_appraiser\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"name_appraiser\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>NMC No. of Appraiser<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"nmc_no_appraiser\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nmc_no_appraiser\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Last Revalidation Date<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"last_revalidate_date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date form-control\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"last_revalidate_date\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Next Revalidation Date<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"next_revalidate_date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date form-control\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"next_revalidate_date\" \/><\/span>\n        <\/div>\n        <div class=\"col-full\">\n            <h6 class=\"mb-4\"> Professional Indemnity- (Nurses only) - We recommend that you take membership with a Medical Defence Organisation. If you are already a member, please provide details of your membership. Please forward copy with your application. <\/h6>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Defence Body (RCN \/ Unison)<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"defence_body\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"defence_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-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-full\">\n            <h6 class=\"mb-4\">TUNIC DETAILS - Please tick your tunic & scrub size below in UK sizes, such as XS - XXL and ladies 8 \u2013 24.<\/h6>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Male<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"male\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"male\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Female<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"female\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"female\" \/><\/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=\"2244\">Previous<\/button>\n\t\t\t\t<button class=\"uacf7-next\"\n\t\t\t\t\tdata-form-id=\"2244\">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\n\t\t<div class=\"uacf7-step uacf7-step-2244 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-full\">\n            <h6 class=\"mb-4\">Declarations & Consent<\/h6>\n            <p class=\"mb-4\">To provide you with a compliant and efficient recruitment service, Remity Staffing will need to undertake a range of checks which will involve accessing, processing, sharing and storing your personal data. We will also be required to share your personal data with our customers and their auditors to find you work, manage your placements and pay you as well as complying with our legal and contractual obligations.<\/p>\n            <p class=\"mb-4\"> I have read a copy of the Agency Worker Handbook which outlines the goals, policies, benefits and expectations of Remity Staffing and its Clients, as well as my responsibilities as an Agency Worker. I have familiarised myself with the contents of this handbook. By my signature below, I acknowledge, understand, accept and agree to comply with the information contained in the Agency Worker Handbook provided to me by Remity Staffing. I understand this handbook is not intended to cover every situation which may arise whilst on assignment, but is simply a general guide to the goals, policies, practices, benefits and expectations of Remity Staffing.<\/p>\n            <p class=\"mb-4\">I give permission for Remity Staffing to send me marketing information. This may include details about vacancies and referral initiatives.<\/p>\n            <p class=\"mb-4\">I give permission for Remity Staffing to process my personal data to undertake a check of my identity and address to facilitate provision of job search and placement services.<\/p>\n            <p class=\"mb-4\">I give permission for Remity Staffing to process my personal data to undertake a check of my Professional Registration status (and if appropriate revalidation status) with the relevant Professional \/ Regulatory Body to facilitate provision of job search and placement services.<\/p>\n            <p class=\"mb-4\">I give permission for Remity Staffing to apply for an Enhanced DBS Check \/ verify my existing DBS certificate with the DBS Update Service or check my Disclosure Scotland membership when I register and on an ongoing basis as required to ensure compliance to facilitate provision of job search and placement services.<\/p>\n            <p class=\"mb-4\">I give my permission for Remity Staffing to process my personal data to check my right to work in the UK status with the UKBA \/ Home Office \/ Embassy to facilitate provision of job search and\nplacement services.<\/p>\n            <p class=\"mb-4\">I give my permission for Remity Staffing to contact and share my personal data with any organisation where I have worked to verify my employment history or to obtain\/validate a reference to                facilitate provision of job search and placement services.<\/p>\n            <p class=\"mb-4\">I give permission for Remity Staffing to process my personal data to obtain a work health assessment or validate my occupational health and vaccination status to facilitate provision of job search and placement services.<\/p>\n            <p class=\"mb-4\">I give permission for Remity Staffing to process my personal data to verify my qualifications and training certificates to facilitate provision of job search and placement services. <\/p>\n            <p class=\"mb-4\">I give permission for Remity Staffing to process my personal data and sensitive personal data including bank details and NI number to facilitate payment into my account. I also give permission for such data to be shared with Remity Staffing\u2019s accountants and payroll\/factoring suppliers.<\/p>\n            <p class=\"mb-4\">I consent to all the data contained in my personal file being made available to external framework auditors, organisations where I have been placed and any prospective customers for audit, review and inspection purposes.<\/p>\n            <p class=\"mb-4\">I give consent to Remity Staffing to disclose any matter regarding pervious dismissals, warnings, complaints or professional body referrals to prospective employers.<\/p>\n            <p class=\"mb-4\">I explicitly agree to abide by all Data Protection Laws with regard to all information regarding Remity Staffing and its clients, candidates, patients and any other third party who I interact with during my registration or service with Remity Staffing. I will not discuss information either\nverbally or in writing and if I am unsure about how to treat any information, I shall immediately contact Remity Staffing for advice and clarification<\/p>\n            <p class=\"mb-4\">For the purpose of the Working Time Regulations 1998 (as amended), You must consent to work in excess of an average of 48 hours per week or Opt opt using the tick boxes below. I understand that I may withdraw this consent by giving Remity Staffing not less than three months\u201f notice. Your registration with Remity Staffing can be terminated at any time following unsatisfactory work reports.<\/p>\n            <p class=\"mb-4\">Remity Staffing has a legal basis to process data and will do so in line with all Data Protection Laws. By signing this declaration, I agree to the above declarations and confirm I understand\nI have the right to: be informed of, withhold access, amend\/rectify, erase and withdraw my data at any                time.<\/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_vaccin_2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"flu_vaccin_2\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Print 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>Profession<span class=\"required\">*<\/span><\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"profession\"><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=\"profession\" \/><\/span>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Registration No<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"regis_num\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"regis_num\" \/><\/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_declarations_sign\" name=\"declarations_sign\" 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 declarations_sign\">\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=\"declarations_sign\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"declarations_sign-attachment\" class=\"wpcf7_input_declarations_sign_attachment\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"declarations_sign-inline\" class=\"wpcf7_input_declarations_sign_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-declarations_sign\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-declarations_sign\" 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-declarations_sign\" 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 type=\"text\" name=\"sign_text form-control\" id=\"sign_text\"\n                    oninput=\"changeFont(this,'digital_signature-pad_declarations_sign')\">\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=\"declaration_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=\"declaration_date\" \/><\/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=\"2244\">Previous<\/button>\n\t\t\t\t<button class=\"uacf7-next\"\n\t\t\t\t\tdata-form-id=\"2244\">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\n\t\t<div class=\"uacf7-step uacf7-step-2244 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-full\">\n            <h6 class=\"mb-4\"> Candidate Payment Method <\/h6>\n        <\/div>\n        <div class=\"col-full\">\n            <label>Full Name: (I confirm that my chosen payment method is the below)<\/label>\n            <p class=\"text-light\">*Subject to approval by Remity Staffing prior to payment method being approved. Umbrella companies are required to comply with IR35 guidelines. Please check with your consultant if your chosen Umbrella company meets those requirements.<\/p>\n\t\t\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"full_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"full_name\" \/><\/span>\n        <\/div>\n        <div class=\"col-full\">\n            <label>Umbrella Company (please mention)<\/label>\n\t\t\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"umbrella_company\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" name=\"umbrella_company\"><\/textarea><\/span>\n        <\/div>\n        <div class=\"col-full\">\n            <h6 class=\"mb-4\">Please confirm you<\/h6>\n        <\/div>\n        <div class=\"col-full\">\n            <div class=\"radio_checkbox\">\n                <label> Agree to the terms and conditions of the above mentioned Umbrella Company.<\/label>\n                <span class=\"wpcf7-form-control-wrap\" data-name=\"agree_terms\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"agree_terms\" 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=\"agree_terms\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n            <\/div>\n        <\/div>\n        <div class=\"col-full\">\n            <div class=\"radio_checkbox\">\n                <label> Understand that regulation with my mentioned Umbrella Company is my responsibility and that a delay in registration may delay payment.<\/label>\n                <span class=\"wpcf7-form-control-wrap\" data-name=\"agree_regulation\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"agree_regulation\" 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=\"agree_regulation\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n            <\/div>\n        <\/div>\n        <div class=\"col-full\">\n            <div class=\"radio_checkbox\">\n                <label>Consent to Remity Staffing sharing your personal details with your mentioned Umbrella Company for payment for work completed.<\/label>\n                <span class=\"wpcf7-form-control-wrap\" data-name=\"agree_consent\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"agree_consent\" 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=\"agree_consent\" 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=\"m-4\"> Please provide your bank details if you wish to be paid via PAYE <\/h6>\n        <\/div>\n        <div class=\"col-half\">\n            <label>Payee Name (as it appears on account)<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"payee_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payee_name\" \/><\/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-half\">\n            <label>Date<\/label>\n            <span class=\"wpcf7-form-control-wrap\" data-name=\"payment_date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date form-control\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"payment_date\" \/><\/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_payment_sign\" name=\"payment_sign\" 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 payment_sign\">\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=\"payment_sign\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"payment_sign-attachment\" class=\"wpcf7_input_payment_sign_attachment\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"payment_sign-inline\" class=\"wpcf7_input_payment_sign_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-payment_sign\"><span class=\"wpcf7-form-control wpcf7-radio multi_options\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-payment_sign\" 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-payment_sign\" value=\"Type\" \/><span class=\"wpcf7-list-item-label\">Type<\/span><\/label><\/span><\/span><\/span>\n                <\/div>\n                <span data-id=\"group-587\" data-orig_data_id=\"group-587\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n                <input type=\"text\" name=\"sign_text form-control\" id=\"sign_text\"\n                    oninput=\"changeFont(this,'digital_signature-pad_payment_sign')\">\n                <\/span>\n            <\/div>\n        <\/div>\n        <div class=\"col-full\">\n            <div class=\"col-half\">\n                <input class=\"wpcf7-form-control wpcf7-submit has-spinner submit_button\" type=\"submit\" 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