Doctors

Are you interested in escorting patients onÂ international flights, private jets, air ambulance or by road in aÂ car orÂ ambulance within the UK?

We regularly receiveÂ requests from clients to travel to the Middle East, Asia, Europe, Africa and the Americas.

If you are interested,Â we would like to hear from you. You can call us on 020 7637 5511 for an informal conversation or alternatively complete the forms.

If you have any problems filling in this form contact support.

Doctor's Application Form

This form should be completed by doctors seeking to become a member of Harley Street Nurses.

Step 1 of 15 - A bit about

Clinical area of specialty
Not listed?

Please enter provide your specialism
How did you hear about us?
- Search engine
- Social media
- Print advert
- Word of mouth
- Other
Choose all that apply
If other please give details

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Personal details
Title
Name
First Last
Known as
Marital status
Maiden name
Home address*
Street Address Address Line 2 City County Post code Country
Home number
Mobile number
Work number
Pager number
Email
Date of birth
DD slash MM slash YYYY
Age
Nationality at Birth
Current Nationality (if different)

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Are you a British Citizen or European Union National?*
- Yes
- No
Are you a spouse of a British Citizen or EU National?*
- Yes
- No
If you have answered No to either of the above questions please complete the below. Please note, you will be required to provide 2 original forms of ID e.g. Birth Certificate and written permission from the Home Office to take employment.
Passport Number*
Place of Issue*
Date of Issue*
MM slash DD slash YYYY
Date of Expiry*
MM slash DD slash YYYY
Date of Entry into the UK*
MM slash DD slash YYYY
Do you hold a work permit?*
- Yes
- No
Expiry date of work permit*
MM slash DD slash YYYY
Passport Nationality*
Place of Issue*
Passport Number*
Date of Issue*
MM slash DD slash YYYY
Date of Expiry*
MM slash DD slash YYYY

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Name
Relationship
Current Address
Street Address Address Line 2 City County Post code Country
Daytime Number
Mobile Number

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Current Employer Name
Address
Street Address Address Line 2 City County Post code Country
Start date
DD slash MM slash YYYY
End date
DD slash MM slash YYYY
Full or part-time
Type of Organisation
Position Held
Grade
Salary
Duties/Responsibilities
Please give FULL DETAILS
Reasons for Leaving
Previous Employer Name
Address
Street Address Address Line 2 City County Post code Country
Start date
DD slash MM slash YYYY
End date
DD slash MM slash YYYY
Full or part-time
Type of Organisation
Position Held
Grade
Salary
Duties/Responsibilities
Please give FULL DETAILS
Reasons for Leaving

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Name of College/University/Training Hospital/Other
Start date
DD slash MM slash YYYY
End date
DD slash MM slash YYYY
Country
Qualifications obtained
Name of College/University/Training Hospital/Other
Start date
DD slash MM slash YYYY
End date
DD slash MM slash YYYY
Country
Qualifications obtained
Name of College/University/Training Hospital/Other
Start date
DD slash MM slash YYYY
End date
DD slash MM slash YYYY
Country
Qualifications obtained

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Are you a registered nurse?
- Yes
- No
NMC Pin No
Expiry date
DD slash MM slash YYYY
Which parts of the NMC register are you entered?
Tell us about your mandatory course updates
Are you a registered midwife?
- Yes
- No
IV Certificate
Date
DD slash MM slash YYYY
Last Refresher
Annual training in resuscitation of the newborn and interpretation of cardiotocograph traces
Please state any professional associations/society/body to which you belong (e.g. RCN, UNISON, RCM):
Membership Body
Type of membership
Expiry Date:
MM slash DD slash YYYY

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Do you hold current Professional Indemnity Insurance?
- Yes
- No
If yes, who is the insurance body?
Type of insurance
PI Number
Expiry Date:
MM slash DD slash YYYY

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Have you ever been involved in any disciplinary or dismissal proceedings?
- Yes
- No
Are you presently under investigation by the NMC?
- Yes
- No
Have you ever been investigated in the past?
- Yes
- No
Have you ever been subject to professional misconduct?
- Yes
- No
If you have answered yes to any of the above questions, please provide details:

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National Insurance Number
Do you hold a current, full UK Driving Licence?
- Yes
- No
Do you have any endorsements?
- Yes
- No
If yes, please provide details
What form of transport do you have access to?
- Car
- Bicycle
- Public Transport
- Motorbike
- Other
Tick all that apply
Languages Spoken:
Languages spoken
Language Fluency
What is your ethnic origin?

This information is required for monitoring purposes only. However, you are not obliged to give this information

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Please provide details of 2 references whom we may approach for a professional nursing/care services reference: The first being your present or most recent employer and the second being your previous employer. Please provide their work and not home details.
Professional references
Company Name Managers Name Managers Job Title Address Telephone Number Fax Number Email When may we approach your reference?
Please give any additional information you think may support your application, or any information of which you think we should be aware, when considering you for employment.

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I declare that the information given in this application form is true and complete to the best of my knowledge and belief. I understand that knowingly giving false information will disqualify me from registration with Harley Street Nurses. I agree to comply with the current Health & Safety at Work Act.

I understand that my appointment is subject to the receipt of a minimum of two satisfactory references and is subject to enhanced DBS Disclosure.

I authorise Harley Street Nurses to make any other enquires they may feel necessary to support my application.

I understand that I can access the policies and procedures and members handbook via the offices of Harley Street Nurses.
Signature
Date
MM slash DD slash YYYY

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Registration with Harley Street Nurses implies acceptance of our code of confidentiality. You should safeguard the privacy of clients and not disclose ANY information about them to anyone other than those involved in their care, without agreement of the client or someone authorised to act on their behalf. (Information is available in the Members Handbook)
If you are worried by any information you have obtained and consider that you should talk about it to someone else, make an appointment to speak in private to the manager at Harley Street Nurses. Failure to observe these rules will be regarded as serious misconduct, which could result in your employment being terminated.
I have read and I understand the above and I agree to abide by the contents therein
Signature
Date
DD slash MM slash YYYY
OPT-OUT AGREEMENT

The Working Time Regulations which came into effect in 1998, states that a worker’s average working time shall not exceed an average of 48 hours per week, unless the worker agrees in writing that the limit shall not apply in his/her case.
<,p>You have indicated your agreement to work in excess of 48 hours per week. Please sign and date the declaration below.

DECLARATION

I agree to work when necessary, in excess of 48 hours per week. I understand that I may change/terminate this agreement at any time, giving one calendar month's notice in writing.
Signature
Date
DD slash MM slash YYYY

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Bank/Building Society Name
Address
Street Address Address Line 2 City County Postcode
Account Holders Name
Account Number
Sort code
I authorise Harley Street Nurses to pay my weekly earnings directly into the bank or building society whose details I have given above. I understand that my earnings are subject to deduction of National Insurance and Tax.

I confirm that I will notify Harley Street Nurses in writing of any changes to these details.
Signature
Date
MM slash DD slash YYYY

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Language	Fluency

Company Name	Managers Name	Managers Job Title	Address	Telephone Number	Fax Number	Email	When may we approach your reference?

Doctors

Doctor's Application Form

Step 1 of 15 - A bit about

Personal details

OPT-OUT AGREEMENT

DECLARATION