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Section 1: Personal Details

Section 2: Professional Qualification

Section 3: WORK EXPERIENCE AND REGISTRATION

SECTION 4: COMPLIANCE

SECTION 5: DOCUMENTS

SECTION 6: DECLARATION

I declare that the information given by me on this application form is accurate and correct. I can confirm that I am of sound physical and mental health and accept full responsibility for maintaining my general fitness to practice. I understand that in this form I may have supplied information which constitutes sensitive personal data, as defined in the Data Protection Act 1998. I give my consent to Priority Professional Placements to process such data for the purposes of health and safety and also as may be necessary for NHS audit and law and tax enforcement or assessment purposes. I consent to such information being passed on to such persons as shall be necessary for the purpose of assessing my suitability for an assignment.