For a free consultation:+44 800 051 9387

Personal Details


Gender:
Male
Female

Contact Details



Emergency Contact Details



Immigration Status


Permanent Residency Status:
Yes
No

Proof of Identification


Do you hold a current Driving License?
Yes
No
Do you have your own transport?
Yes
No

Please provide two copies of documents as proof of identification. (e.g. Passport/Driving Licence and household bill showing address) Plus, two passport size photographs of yourself, signed on the back with details of your Professional Society number.

Bank, Taxes & Practitioners Details

Bank Details


Tax Status

PAYE
Yes
No
P45 Enclosed
Yes
No
P60 Enclosed
Yes
No
LTD Co.
Yes
No
VAT Registered
Yes
No

Enclose VAT Certificate

Enclose Certificate of incorporation

Enclose Ltd Co Bank Statement

All Agency Workers, working through a LTD or PersonalAcad Services Company, must complete separately the Yani Care Solutions Agreement (IR35)

Self Employed Professional
Yes
No

Please note it is a HMRC requirement to supply UTR and NI numbers. If your UTR number is not available, please confirm in writing that you are registered as self- employed with the HMRC giving your tax office address.


Limited Company Bank Details



General Practitioners Details



Professional Society/Union*


Are you currently under investigation by the Professional Society or any other organisation?
Yes
No
Have you ever been investigated by the Professional Society or any other organisation?
Yes
No

*it is the responsibility of the applicant to inform Yani Care Solutions of any changes or restrictions to their registration.

Academia

Education & Training incl. Post Qualification Experience


Entry onto the Specialist Register?
Yes
No
Do you hold a Section 12 if appropriate?
Yes
No
Do you hold a Certificate of Ionising Radiation if appropriate?
Yes
No


Insurance

Do you hold Professional Indemnity Insurance:
Yes
No

A copy of the Insurance certificate must be supplied with this application form.

Do you hold Medical Malpractice Insurance:
Yes
No

A copy of the Insurance certificate must be supplied with this application form.

Do you hold Union Indemnity Insurance:
Yes
No

A copy of the Insurance certificate must be supplied with this application form.


Availability To Work


Nights:
Yes
No
Odd Days:
Yes
No
Holidays:
Yes
No
Weekends:
Yes
No
Full Time:
Yes
No
Long Term:
Yes
No
0 - 50 Miles:
Yes
No
51 - 100 Miles:
Yes
No
101 - 150 Miles:
Yes
No
Are you registered with any other Agencies:
Yes
No

References


References must be from the past twelve months and one must be from your most recent/ current employer.

References must be from the past twelve months and one must be from your most recent/ current employer.


Appraisal Details


Please supply the name of Medical Practitioner/GP principle that is entered on the specialist register with which formal arrangements have been made to be regularly appraised.

Please supply details of your Continual Professional Indemnity (CPD) action plan.

Please supply a copy of the transcript of your last appraisal.

Criminal Records

Declaration of Criminal Record


Please ensure that you complete the enclosed CRB Form and provide evidence of Police Clearance from your country within the past six months.

Rehabilitation of Offenders Act 1974 (exceptions) Order 1975

Due to the nature of the work for which you are applying, the provision of Section 4 (2) of the Rehabilitation of Offenders Act 1974 does not apply by virtue of the Rehabilitation of Offenders Act 1974 (exceptions) Order 1975.

Applicants are therefore NOT entitled to withhold information about convictions which for purposes are ‘spent’ under the provisions of the Act. In the event of employment, any failure to disclose such convictions will result in your removal from our register.

Any information you may give will, of course, remain strictly confidential. Yani Care Solutions may contact you for your permission to disclose such details if relevant to the position you are applying for.

Have you ever been Police checked?
Yes
No
Have you ever been convicted of a criminal offence?
Yes
No

If ‘Yes’, Please complete the next section.


Details of Any Convictions



Declaration (Mandatory Training)


I understand that it is my responsibility to undergo an annual appraisal and attend mandatory training in the following disciplines:

Moving and Handling; Health and Safety; Fire Procedures; Infection Control; COSHH; RIDDOR; Risk Incident Reporting; Complaints Monitoring; Lone Worker Training.

Checklist

The following is a list to assist you in completing the application process. In order to avoid any unnecessary delays to your registration process please ensure you enclose original documents where requested.

Please tick to confirm documents enclosed.


Detailed CV – 10 years working experience if applicable, gaps no more than 3 months
Application Form. Please ensure this is completed in full, signed throughout where required.
Two recent passport size photographs (with your name and Professional Society number written on the back)
Verified Personal Identification. Please provide the original of your passport.
Immigration Status/Eligibility to Work. Please provide your original employment status and associated right to work documentation, supporting letters issued from the Home Office or Worker’s Registration documents, including your work permit number if applicable.
Registered Higher Qualifications. Please provide your original documentation, to include professional qualifications and additional supporting documents and certificates to substantiate your CV.
Either your Original Full Registration Professional Society certificate, or your original proof of entry Your Professional Society Annual Retention Fee Letter. , or your original proof of entry
Consultancy Agreement (IR35) - in the event Agency Worker is using a LTD or Personal Services Company.
Union Indemnity Insurance certificate
UK CRB Enhanced Disclosure. Please also provide two forms of identification to include your current address. These documents must be dated within three months and can be returned if required.
Police check from country of origin. If you have become resident in the UK in the last six months or intended to become resident, you will need to supply us with an original police check from your country of origin. This must not be no more than three months old at the time of registration. This is in addition to the UK CRB Enhanced Disclosure.
Basic Life Support certificate or higher.
Certificate of Incorporation certificate (Ltd Co. applicants only)
Ltd Co Bank Statement (LTD Co. applicants only)
VAT certificate (if using LTD Company)
Professional Indemnity Insurance certificate
Medical Malpractice Insurance certificate

Work Details


Working Times Regulations


The working Times regulations 1998 (“The Regulations”) require the Company to limit your average weekly working time to 48 hours unless you agree with the Company that the limit shall not apply to you. The Company wishes to have an agreement with you. It proposes an agreement (which will apply until terminated by notice) on the basis that:
1. The 48 hour limit on average weekly time will not apply to you.
2. You may terminate the agreement (so that the 48 hour time limit would apply to you) by giving the person at Yani Care Solutions to whom you usually report four weeks written notice. Under the Regulations, Yani Care Solutions must keep records relating to your working time. This is the case whether or not you reach an agreement with the Company about waiving working time limits.
If you accept Yani Care Solutions proposals, please sign below. This document will then be the record of agreement.

Mandatory Induction, Information & Training Declaration


I the undersigned hereby declare that I acknowledge the documentation required by Yani Care Solutions and that I am already trained to the NHS standards in all the mandatory areas.

In the event that I feel I require further training in any area I will inform Yani Care Solutions without delay.

I fully understand that should any information I have presented within this application comes to light, following my engagement with the prospective employer, which shows that this declaration was found to be misrepresent, or false, my employer may terminate my employment with immediate effect.


Access to Medical Records


I the undersigned hereby give permission to Yani Care Solutions, St James House, Pendleton Way, Salford, Greater Manchester, M6 5FW, to have access to my medical records pertinent to my immunisation and blood test history.

Declaration

I fully understand that should my declaration be found to be incorrect or any information that is provided with this application pack prove to be factually incorrect or misleading, that any assignment I am on will be terminated with immediate effect and withhold any payments due for work completed and I fully understand that any payments that have been made for work completed may have to be refunded. I acknowledge that I have been given a copy of the Agency Worker Handbook and Terms and Conditions and by Yani Care Solutions and I will fully abide by those Terms and Conditions.

Furthermore, I duly authorise Yani Care Solutions and associated companies or its agents/ nominated third parties to verify the information that I have provided, as required, and in the common interests of patient safety. In addition I agree that Yani Care Solutions and associated companies may forward to authorised recipients, and in strictest confidence, confidential details held on my file in relation to my registration, employment and/or Occupational Health Status.

I declare that I will notify Yani Care Solutions and associated companies of any changes to my circumstances immediately. Including but not limited to changes relating to any clinical complaints or my clinical competency, criminal investigations or changes to my occupational health or professional registration status.

×

Form Submission

You are about to submit your application form to the Yani Recruit Team. Please ensure that all your information is accurate and up to date because you will only be allowed to apply once.
Proceed?

Excellent quality of care, governance and the delivery of successful positive outcomes are central to our organisational ethos of the organisation.

Copyright 2025 Yani Care. All Rights reserved.

]