DocuSign Envelope ID: 130EA653-56A4-4CC0-AC34-6713702B8589

Registration Form
Personal

Title: Surname: Zaman First Name(s): Qumar

Mr.
Other Name(s):

Current Address: National Insurance Number: SN760918c

53Lyndhurst Cresent Swindon
Date of Birth: 15/11/76

Mobile No: 07956954467

Email Address:
Post Code: Sn32rw [email protected]

Professional Registrations? (Delete where appropriate) GMC / HCPC / NMC / Performers List N/A
Number: nil Renewal Date: nil

Next of Kin Name: Sabahat Relationship to you: wife

Address and Post Code
53Lyndhurst Cresent Swindon

Mob No: nil

Grade/Band Specialties
Band 2 Nursing [diploma]

Appraisals & Revalidation

Please detail below the arrangements you have made to be appraised for GMC / NMC revalidation by a medical
practitioner / confirmer entered onto the Specialist Register or higher grade on the NMC. In the case of General
Practitioners, the appraiser must be (of qualified to be) a GP Principal.

Name of Appraiser / Confirmer: ________________________________________________

Date of Appraisal: ________________________________________________

For Doctors only:

Name of Designated Body: ________________________________________________

Name of Responsible Officer: ________________________________________________

Employment

HcP is committed to operating under the ‘Guidance for employers’ in relation to the sharing of appropriate and relevant
information between healthcare organisation about the conduct or performance of a healthcare worker where there is an
identified risk to public and (or) patient safety.

Have you ever been or are you the subject of any professional misconduct proceedings?
YES : NO : X (If yes please give brief details on a separate piece of paper)

CPW Resourcing Ltd ta Healthcare Professionals. Company Number 07490243, 30B Wilds Rents, London SE1 4QG
Tel 02078815608 email :[email protected]
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Employment

Please detail the last 5 years of your employment:

Name of the Employer Position held Dates of Employment

LashbrookNursing home Reading Health care Assisstant 2011 to 2016

Princess Lodge nursing Home Swindon Health care Assisstant 2016to2018

One call 24 hours Agency Health care Assisstant 2018 to 2019

First Active365 Agency Health care assisstant 2019 to 2021

Curriculum Vitae enclosed with no gaps for the last 5 years.

Yes No.
X

Professional Referees

We require you to hold references relating to your most recent engagements. Please provide contact details for two
referees who you worked with on your two most recent positions.

Referee Name and Position: Referee Name and position:

Abida Parveen RN Victoria Nathanisal RN

Location: Location
Reading Stanford
Email address: Email address:
[email protected] [email protected]
Telephone number: 07715333374 Telephone number:
447783572584
Referee Name and Position: Referee Name and position:

Location: Location

Email address: Email address:

Telephone number: Telephone number:

I understand and agree to Healthcare Professionals disclosing copies of my references to their clients for the purposes
of finding me assignments.
01-02-2021 | 20:31 GMT
Signed Date

CPW Resourcing Ltd ta Healthcare Professionals. Company Number 07490243, 30B Wilds Rents, London SE1 4QG
Tel 02078815608 email :[email protected]
DocuSign Envelope ID: 130EA653-56A4-4CC0-AC34-6713702B8589

Qualifications and Training

Please list all of your professional qualifications held and any training courses undertaken including Post Graduate Diploma / Courses.
Professional qualifications and training will be verified. Please continue on a separate sheet if necessary. Please provide original copies at
interview.

Qualification Place Where Obtained Dates from / to Certificate

Attached?
General nursing Diploma Karachi Pakistan
Karachi 2005
2005 Yes

Dementia course reading uk 2015 Yes

Right to Work in the UK

I confirm I am entitled to work in the UK on the following basis:

Are you an EEA National/Citizen?

Yes (please go to No (please answer Kindly Mention the

next page) X next question) Visa details in the
text box below.

If you do not hold a British / EU Passport, do you hold any of the following:

Indefinite Leave to Remain in the UK:  X Student Visa: 

Ancestry Visa:  Biometric Residence Permit: 

Work Permit / Sponsorship (Tier 2):  Working Holiday Visa / Youth Mobility Visa (Tier 5): 

Spousal / Partnership Visa:  Other (Please Specify): ____________________

Please list the expiry date of the visa: _____/_____/_________

Equal Opportunities

Healthcare Professionals is an equal opportunities Recruitment Agency. We ensure that all applicants are
submitted for vacancies based solely on the basis of merit. In order to monitor the effectiveness of our policy,
we ask all applicants to provide the following information below:

Kindly circle the appropriate description:

White Chinese Bangladeshi

Indian Pakistani X Asian Other

Black – African Black Caribbean Black Other

Do you consider yourself to have a disability?

Yes No.
X

Specify if you wish: ……………………………………………………………………….…………………………

……………………………………………………………………….………………………………………………...

……………………………………………………………………….………………………………………………...

CPW Resourcing Ltd ta Healthcare Professionals. Company Number 07490243, 30B Wilds Rents, London SE1 4QG
Tel 02078815608 email :[email protected]
DocuSign Envelope ID: 130EA653-56A4-4CC0-AC34-6713702B8589

Rehabilitation of Offenders Act 1974

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

Have you been convicted of a criminal offence, been bound over or cautioned Y N
or are you currently the subject of any police investigations, which might lead e o
to a conviction, an order binding you over or a caution in the UK or any other s
country? X
If yes, please provide details of the criminal offence, order binding you over, a caution, including
approximate date, the offence and the authority and country with dealt with the offence.

Protection of Children

For all locum staff and permanent staff we register On Convictions – Home Office Circular HO102/88

In accordance with the above mentioned circular, you are required to provide us with your current DBS, to
check the existence and content of any criminal record.

Have you worked with children in an NHS Trust in the last year?

Yes No. X

If YES, for which NHS

Trust……………………………………………………………………………………

Disclosure & Baring Service (Police Checks)

I enclose a copy of current DBS Disclosure. I consent to the above information being checked against police
records and for Healthcare Professionals to have authority to check my DBS on the update service if
applicable. I am aware that any spent convictions will be disclosed. If I do not have a valid DBS on the update
service I will supply information so that Healthcare Professionals can complete a new DBS on my behalf.

Signed………………………………………………………
01-02-2021 | 20:31 GMT
Date……………………………………………………...

If your DBS is not up to date on the Update service, you will need to complete a New DBS until you are on the
update service. We will apply for you. You must contact the update service within 13 days of your date of issue
of your new DBS to be eligible for the update service.

CPW Resourcing Ltd ta Healthcare Professionals. Company Number 07490243, 30B Wilds Rents, London SE1 4QG
Tel 02078815608 email :[email protected]
DocuSign Envelope ID: 130EA653-56A4-4CC0-AC34-6713702B8589

(Please continue on a separate sheet for any additional information).

Have you ever been or currently the subject to any “Fitness to Practice” proceedings by an appropriate licensing or
regulatory body in the UK or any other country?

Yes No.
X

Have you been suspended from duty with any organisation or with the GMC, NMC or any other Professional
Regulatory Body?

Yes No.
X

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.
……………………………………………………………………….…………………………
……………………………………………………………………….…………………………
……………………………………………………………………….…………………………
I declare that, if in the future, I am convicted of a criminal offence, bound over or cautioned, under investigation by the
GMC, NMC or any other Professional Regulatory Body, the subject of any ‘Fitness to Practice’ proceedings, or
suspended from duty by any other employer or agency, I will inform Healthcare Professionals immediately. I am
willing for Healthcare Professionals to apply for a new DBS if I am not on the update service and if requested forward
information of such to any hospital where I am assigned

Signed: ………………………………………………………….
01-02-2021 | 20:31 GMT
Date………………………………………………

HcP is committed to operating under the ‘Guidance for employers’ in relation to the sharing of appropriate and
relevant information between healthcare organisation about the conduct or performance of a healthcare worker where
there is an identified risk to public and (or) patient safety.

Have you ever been or are you the subject of any professional misconduct proceedings?
YES : X NO :  (If yes please give brief details on a separate piece of paper)

Occupational Health

Please indicate which of the following two statements applies to you tick either statement A or B:

A. I am not aware that I have a health condition or disability that might impair my ability to undertake
X
effectively the duties of the position that I have been offered. I confirm that I am aware of the Department of
Health’s guidelines on AIDS/HIV infected health care workers issued in March 2007 and agree to abide by
these recommendations.
B. I do have a health condition or disability that might affect my work and may require special adjustments
to my work or my place of work.
N.B A full Occupational Health Declaration will be sent out for completion for full Occupational Health
Clearance on confirmation of first shift with Healthcare Professionals. Should the full Health Declaration not
be returned you will be cancelled from the shift and any shifts furthermore until the Form is completed
and returned?

CPW Resourcing Ltd ta Healthcare Professionals. Company Number 07490243, 30B Wilds Rents, London SE1 4QG
Tel 02078815608 email :[email protected]
DocuSign Envelope ID: 130EA653-56A4-4CC0-AC34-6713702B8589

Declarations

Working Time

In compliance with the implementation of the Working Time Regulations, working time should not exceed 48 hours per
week (averaged over a period of 17weeks) and Healthcare Professionals recommends this practice. However, Members
may wish to waive this right, and should indicate their preference by ticking Yes/No in the box provided below. Staff can
change their chosen option by giving appropriate notice. Working time shall include only the period of attendance at each
individual assignment through Healthcare Professionals.

( ) Yes, I may wish to work for more than 48 hours a week.

( X ) No, I do not wish to work for more than 48 hours a week.

Qumar Zaman 01-02-2021 | 20:31 GMT
Signed: …………………………………… Print Name: ……………………................................. Date: ……………………

Handbook
I have received, read and understood the contents of the Healthcare Professionals Recruitment Candidate Handbook.
The content of the same has been discussed with me in detail and by my signature below, I acknowledge and agree to
comply with the information contained in the Healthcare Professionals Agency Handbook.
Updates to this manual that happens time to time will be promptly notified to me by Healthcare Professionals and I
agree to familiarise myself with these changes before undertaking any further shifts through the agency.
Qumar Zaman 01-02-2021 | 20:31 GMT
Signed: …………………………………… Print Name: ……………………................. …………….Date: ……………………

Terms & Conditions

I acknowledge that I have given a copy of the current terms and conditions of the services issued by Healthcare
Professionals, which is mine to keep. I have read and understood the terms/ conditions and agree to abide to them
completely.
Qumar Zaman
Signed: …………………………………… Print Name: ……………………................................. Date:01-02-2021
…………………… | 20:31 GMT

Data Regulations & 3rd Party Audit Consent

rd
We will be undergoing 3 party audits going forward to ensure our compliance is in order. You are allowing in this audit
to pass on information which otherwise would be considered confidential during this audit. This will include and not be
limited to payroll information from 3rd parties such as payslips from umbrella companies and accounting firms.

You hereby acknowledge you have read and signed the GDPR Data consent form and you consent to us collecting and
processing your personal data and disclosing this information to Clients and other relevant third parties for the purpose of
seeking employment on your behalf & auditing your personal data on file for compliance and quality assurance purposes?
Qumar Zaman 01-02-2021 | 20:31 GMT
Signed: …………………………………… Print Name: ……………………................................. Date: ……………………

• I will comply with the Department of Health guidelines on HIV/AIDS; MRSA; HEP ‘B’/’C’ (HSC 2000/20)
• I will comply with all NHS Employers regulations currently in place including regular health screening and I am not
aware of any condition, medical or otherwise, which would affect or limit my employment or performance other than those
declared in my Occupational Health Form
• I acknowledge that my personal details will be stored and handled correctly by HcP in accordance with the Data Protection
Act, however, I grant my consent for these records to be shared with any framework provider or professional body, any
client organisations and any MSP (Managed Service Provider) or Neutral Vendor that is appointed by a client organisation
• I acknowledge that should I reach the 12-week Qualifying Period under the Agency Workers Regulation, I may be asked
for, and will provide, further documentation as evidence of qualifying period, if HcP deem it necessary.
• I declare that I have appropriate professional indemnity in place to cover the entirety of my professional scope of
practice. I understand that signing this declaration and failing to have the appropriate cover in place at all times would
result in me being personally liable for any claims.
• I am aware of my legal obligation to comply with the requirements of IR35 whilst working through a personal service
company

Print name: Signature: Date:

Qumar Zaman 01-02-2021 | 20:31 GMT

CPW Resourcing Ltd ta Healthcare Professionals. Company Number 07490243, 30B Wilds Rents, London SE1 4QG
Tel 02078815608 email :[email protected]
DocuSign Envelope ID: 130EA653-56A4-4CC0-AC34-6713702B8589

CPW Resourcing Ltd ta Healthcare Professionals. Company Number 07490243, 30B Wilds Rents, London SE1 4QG
Tel 02078815608 email :[email protected]