Richmond Medical Agency

Register with Richmond Medical Agency

To register with Richmond Medical Agency - please fill out the form below and the appropriate Member of Staff will contact you at the earliest opportunity.

Fields marked with* are required

First Name*
Surname*
Gender		MaleFemale
D.O.B *		(DD/MM/YYYY)
Nationality
Country of origin
Address *
Postcode
Telephone (Home)*
Telephone (Mobile)*
Telephone (Work)
Bleep
E-mail *
Fax
National Insurance Number
Speciality *
Grade *
Available from
Name and Address of Present Employer
Telephone Number
GMC/GDC Registration *
Registration number *
Type *
Registration expiry *
Other information
Immigration Status:
Do you hold a British passport?		Yes No
Do you hold a 'Student visa' ?		Yes No
Do you need a work permit to be able to work in UK?		Yes No
Where did you hear about us?		Please Select... 123Doc.com BMJ Careers Fair BMJ Advert Hospital Doctor Pulse Friend/Colleague Medical Staffing Yahoo Google Other Search Engine Other
Professional Referees:
Name
Position
Address
Postcode
Tel
Fax
Email
Name
Position
Address
Postcode
Tel
Fax
Email
Fitness to Practice:
Have you ever been the subject of Professional Misconduct Proceedings?		Yes No
Have you obtained CRB Clearance?		Yes No
I have read the Terms and Conditions *
The information you supply us is in strict confidence and will not be used for any other purpose in line with the 'Data Protection Act'

Note: To ensure registration is fully completed please ensure the following is returned to Richmond Medical Agency:

• A current and up to date CV
• A copy of your GMC Certificate
• Completed CRB Form
• Completed Registration Completion form
• Evidence of eligibility to work in the UK
• A current virology report
• A current copy of Immunity to Rubella and health records stating all immunity is up to date
• A Copy of passport for ID security purposes and NI number
• 2 passport size photographs for Identification badges
• Confirmation of membership to MDU/MPS
• Download and confirm you have read the Terms and Conditions
• Evidence of Professional Indemnity Insurance
• Next of Kin
• Emergency contact telephone number

This information can be returned via:
Fax on 01784 422318
Email to Doctors@rma-locums.co.uk
Post to RMA House, 157 Stanwell Road, Ashford, Middx, TW153QN

You will also be given the opportunity to upload any of these documents once you have completed this form.

Visit our dedicated GP (General Practitioner) site at S&T Medical

Contact Richmond Medical Agency