Sirona Medical Candidate Application Form

Personal Details

Title *

Example Mr, Mrs, Dr, Miss, Ms

Name *

First

Last

Middle Names *

Male
Female
Non-Binary

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Numbers

Mobile Number

Home Number

Email *

Date of Birth

National Insurance Number

Do You Hold a UK Driving Licence

Yes
No

Emergency Contact

Name

Relationship

Number

Email *

Right to Work Details

Nationality

Do you require a Visa to work in the UK?

Yes
No

Visa type:

Professional Qualifications

Primary Qualification Held

Where was this qualification obtained?

Date of Qualification

Please list any other qualifications you have:

Professional Registration

Who is your professional registration held with?

Expiry Date

Do you have any other conditions to practice?

Yes
No

If you selected yes, please state your conditions?

Appraisal & Revalidation

Date / Time

Date / Time (copy)

Name of Appraiser

Location of Appraiser

When are you due to be revalidated? (If applicable):

Professional Referee Details

Please provide a minimum of two clinical, professional referees. One must be from your present or most recent employer and both must be a senior grade to yourself who have supervised your work. References must cover at least 3 years of clinical employment. By signing this application form, you confirm that you are happy for Sirona Medical to contact your referees unless otherwise stated.

Referee 1 *

First

Last

Referee Job Title

Place of Work

Ward

Contact Number

Professional Email Address *

Employment Dates

Referee 2 *

First

Last

Referee Job Title

Place of Work

Ward

Contact Number

Professional Email Address *

Employment Dates

Rehabilitation of Offenders / DBS Checking

Due to the nature of the work for which you are applying, you are exempt from the provision of section 4(2) of the Rehabilitation of Offenders Act 1974. Applicants are therefore required to give information about convictions which for other purposes are “spent” under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation to the positions in which the order applies. Failure to declare a conviction that later comes to light, may require us to exclude you from our register or terminate an assignment early.

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Do you have any convictions, cautions, reprimands or final warnings?

Yes
No

At present, are you the subject of criminal charges or disciplinary action?

Yes
No

Are you currently subject to any investigation by an employer or professional body, or have you been in the past?

Yes
No

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Have you had an enhanced DBS check (formerly CRB) within the last 12 months?

Yes
No

Is your DBS part of the annual, online update service?

Yes
No

Do you provide consent for Sirona Medical to regular check the status of your online DBS?

Yes
No

If your DBS certificate is part of the annual update service, you will need to provide us with a full, clear copy of your Certificate before we can complete the check online. If you do not have a DBS certificate that is part of the annual update service, then we will need to complete a new check through Sirona. The Compliance team can advise you on how to do this. We strongly advise that once you receive your new certificate that you join the DBS update service for an annual cost of £13. This will stop the need for a new disclosure being made every year. We will be happy to provide more information regarding the DBS update service should you require it.

Staff Handbook

Please click link to review and submit Staff-Handbook

Once you've completed the Staff Handbook, please return to this page and tick to confirm. Upon registering with Sirona Medical you will have received a copy of our Staff Handbook which includes important information. You must read and familiarise yourself with the contents of our handbook, and in turn we will keep you updated with any changes.

Please Confirm

Tick to Confirm

I confirm that I have received, read and fully understood Sirona Medical staff Handbook and will adhere to its contents.

Working Time Regulations

The Working Time Regulations 1998 requires Sirona Medical to limit your average working week to 48 hours, unless you agree that this limit does not apply to you.

I do not agree to limit my working week to 48 hours maximum
I agree to limit my working week to 48 hours maximum

Please Sign & Date

Date / Time

Date

Time

Professional Indemnity Cover

Who is your professional indemnity cover held with?:

Policy Number

Expiry Date

Declarations

By signing below, you are confirming the following declarations:

I am permitted to work in the UK, and should I have any restrictions on my right to work within the UK these have been declared within this form.

Confirmation

I understand that the information I have provided on this form will be used by Sirona Medical for registration purposes only and they will retain these details for as long as reasonably necessary in accordance with the Data Protection Act 1998.

Confirmation

I am not aware of any condition, medical or otherwise, which could affect my employment or limit my performance, other than those I have previously declared within my medical questionnaire.

Confirmation

I confirm that I have received, read and fully understood Sirona Medical Staff Handbook and will adhere to its contents.

Confirmation

I give my consent for Sirona Medical to carry out a DBS status check for the duration of my registration with them.

Confirmation

I am aware that certain compliance documents expire and it is my responsibility to ensure they are kept up- to-date.

Confirmation

I consent to my personal information being made available for the purpose of audits and any relevant third parties. This applies to all of the documentation I have provided to Sirona Medical including, but not limited to, my DBS, fitness to work certificate, reference checks, CV and right to work documents.

Confirmation

Full Print Name *

Signature

Date / Time

Date

Time

Sirona Medical Candidate Application Form

Personal Details

Emergency Contact

Right to Work Details

Professional Qualifications

Professional Registration

Appraisal & Revalidation

Professional Referee Details

Rehabilitation of Offenders / DBS Checking

Staff Handbook

Working Time Regulations

Professional Indemnity Cover

Declarations

Thank you for completing the Sirona Medical Candidate Application Form