FINANCIAL BACKGROUND

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?
If 'yes' selected, please provide details
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?
If 'yes' selected, please provide details
Do you as an individual or any member of the partnership have any current financial or business interests in a registered provider?
If 'yes' selected, please provide details, including CQC ID Number
Will your carrying on of the regulated activities proposed in this application depend upon formal contractual relationships with any other service provider?
If 'yes' selected, please provide details, including CQC ID number
Who is to take on the Registered Manager Duties?
If 'other registered manager' selected, please fill in here
If more than two partners, please include all their info here
please upload a copy of your DBS as an image or PDF
if this has not been received, leave empty
Are you currently the subject of, or have been subject of any safeguarding investigation?
if 'yes' selected, please provide details
Do you wish to provide alternative contact details for this application?
if 'yes' selected, please provide details

PREVIOUS HISTORY

Please upload CV providing details of the recent 15 years employment history, including commencing and leaving in addition to your reason for leaving.
if applicable, please provide details
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
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)?
if 'yes' selected, please provide details
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?
if 'yes' selected, please provide details
Have you ever been declared bankrupt or been involved in an organisation or partnership that went into administration or receivership?
if 'yes' selected, please provide details
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?
Please give your GP title, name, last name, surgery name, address, town, post code
I give permission for the Care Quality Commission to contact my doctor or their surgery
I give permission for the Care Quality Commission to contact my referee.
How Many Dentist Parties Are Buying the Practice?