Phone First Name * Last Name * Address * Postcode * Personal Mobile Phone * Personal Email Address * Practice/organisation Name * Practice/organisation address * Postcode * Practice/organisation Phone * Practice/organisation email address * FINANCIAL BACKGROUND Bankruptcy / Insolvency * NO YES Have you (or any member of the partnership) ever been declared bankrupt or have been subject to any other insolvency processes or proceedings resolved or otherwise? Details bankruptcy / insolvency If 'yes' selected, please provide details Administration / Insolvency * NO YES Have you (or any member of the partnership) ever been a director or equivalent in an organisation or partner in a partnership that went into administration or was subject to any insolvency processes or proceedings, resolved or otherwise? Details administration / insolvency If 'yes' selected, please provide details Financial interest * NO YES Do you as an individual or any member of the partnership have any current financial or business interests in a registered provider? Details If 'yes' selected, please provide details, including CQC ID Number Financial interest * NO YES Will your carrying on of the regulated activities proposed in this application depend upon formal contractual relationships with any other service provider? Details If 'yes' selected, please provide details, including CQC ID number Registered Manager * Partner One Partner Two Other Who is to take on the Registered Manager Duties? Partner One First Name Partner Two First Name Partner One Last Name Partner One DOB Partner Two Last Name Partner Two DOB Partner One Mobile Phone Partner Two Mobile Phone Partner One Email Address Partner Two Email Address Partner One Address Partner One Postcode Partner Two Address Partner Two Postcode Other Registered Manager First Name If 'other registered manager' selected, please fill in here Other Registered Manager Address Other Registered Manager Postcode Other Registered Manager CQC ID Number Other Registered Manager Last Name Other Registered Manager DOB Other Registered Manager Email Address Other Registered Manager Mobile_Phone Other Partner(s) Details If more than two partners, please include all their info here Copy of DBS * Add Files please upload a copy of your DBS as an image or PDF CQC Countersigned DBS Number if this has not been received, leave empty Safeguarding Investigation * Yes No Are you currently the subject of, or have been subject of any safeguarding investigation? Safeguarding investigation details if 'yes' selected, please provide details Alternative details for correspondence Yes No Do you wish to provide alternative contact details for this application? Alternative correspondence details if 'yes' selected, please provide details PREVIOUS HISTORY Employment History * Add Files Please upload CV providing details of the recent 15 years employment history, including commencing and leaving in addition to your reason for leaving. Employment Gaps if applicable, please provide details Other Agency or Service Registered YES NO Prior to the last 15 years, have you ever been registered as manager or provider of an establishment, agency or service registered under any of the following acts of parliament? Please tick all that apply Other Agency The Registered Homes Act 1984 The Registered Homes Act - amendment 1991 The Children Act 1989 – including child- minding and day-care for children The Nurses Agencies Act 1957 Subject of other investigation * NO YES Are you currently the subject of, or have you ever been subject of any investigation, or proceedings by any professional body with regulatory functions in relation to health or social care professionals (including by a regulatory body in another country)? Other investigation details if 'yes' selected, please provide details Disqualification and/or limitations * NO YES Have you ever been disqualified from the practice of a profession or required to practice subject to specified limitations following a fitness to practice investigation by a regulatory body in the UK or another country? Disqualification / limitations details if 'yes' selected, please provide details Bankrupcy / administration * NO YES Have you ever been declared bankrupt or been involved in an organisation or partnership that went into administration or receivership? Bankruptcy / administration details if 'yes' selected, please provide details Partner One Medical Health NO YES Do you have any physical or mental health conditions which are relevant to your ability to carry on the regulated activities in this application for registration? GP Information * Please give your GP title, name, last name, surgery name, address, town, post code GP Contact Consent YES NO I give permission for the Care Quality Commission to contact my doctor or their surgery Referee First Name Referee Address Referee Postcode Referee Last Name Referee Email Address Referee Phone Number Referee Contact Consent YES NO I give permission for the Care Quality Commission to contact my referee. Additional Information How Many Dentist Parties Are Buying the Practice?