5B

Information on whether—

a

he has any criminal convictions in the United Kingdom;

b

he has been bound over following a criminal conviction in the United Kingdom;

c

he has accepted a police caution in the United Kingdom;

d

he has been convicted elsewhere of an offence, or what would constitute a criminal offence if committed in England and Wales, or is subject to a penalty which would be the equivalent of being bound over or cautioned;

e

he is currently the subject of any proceedings which might lead to such a conviction, which have not yet been notified to the Health Authority;

f

he is currently, or has been where the outcome was adverse, subject to any investigation into his professional conduct by any licensing, regulatory or other body anywhere in the world;

g

he is to his knowledge, or has been where the outcome was adverse, subject to any investigation into his professional conduct in respect of any current or previous employment;

h

he is currently, to his knowledge, or has been where the outcome was adverse, subject to an investigation by the National Health Service Counter Fraud Service in relation to a fraud case;

i

is the subject of an investigation by another Health Authority or equivalent body which might lead to his removal from any of that Authority’s lists or equivalent lists,

and if so, he must give details, including approximate dates, of any investigation or proceedings which were or are to be brought, the nature of that investigation or proceedings, and any outcome.

8

An undertaking to—

a

be bound by the terms of service;

b

notify the Health Authority within 7 days of any material changes to the information provided in the application until the application is finally determined;

c

supply the information required by paragraph 31H of Schedule 1; and

d

provide general dental services in the locality of the Health Authority.

11

Professional experience (including starting and finishing dates of each appointment with an explanation of any gaps between appointments) an explanation of why he was dismissed from any post, and any additional supporting particulars.

11A

The names and addresses of two referees who are willing to provide clinical references for the last two clinical posts where the employment lasted for a continuous period of at least three months, and where this is not possible, a full explanation and the names and addresses of alternative referees.

14

Whether he—

a

is or has ever been subject to a national disqualification,

b

has ever been removed or contingently removed from a list held by a Health Authority or by an equivalent body from an equivalent list,

c

has been refused admission to or conditionally included in a Health Authority list or equivalent list, with an explanation as to why, or

d

is suspended.

17

Consent to the Health Authority requesting from any employer or former employer, licensing, regulatory or other body in the United Kingdom or elsewhere, information relating to a current investigation, or an investigation where the outcome was adverse, by them into the dentist.