Get documents about "LIBERTY CARE EMPLOYMENT LTD
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LIBERTY CARE EMPLOYMENT LTD
127 High Street, Rainham-Kent ME8 8AN
Tel: 01634 388862 Fax: 056011 43186
Email: enquiies@libertycareltd.co.uk
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APPLICATION FORM FOR EMPLOYMENT
Please use capital letters and complete all sections. If you have any difficulty in completing this form, please ask a member of staff
to help you.
In accordance with the Data Protection Act 1998, the data gathered on this application form and the application form profile, is used
by LCEL to inform you of the potential work opportunities by mail, telephone or email. Any sensitive data such as racial, ethnic
origin, religion, health and criminal records is for monitoring and selection processes only. By signing this form, you permit us
(LCEL) to expressly use this information in this way.
PERSONAL DETAILS
Basic Information
Mr/Ms/Mrs __________
Surname: ________________________________ Previous name: (if any) ______________________________
First Name(s): ____________________________
Current Address: ___________________________________________________________________________________________
__________________________________________________________________________________________________________
Post Code: __________________
Home Tel: __________________________ Work Tel: ___________________________
Date Of Birth: ___/___/______ (DD/MM/YYYY) Nationality: _______________________________
Qualification (s): ___________________________________________________________________________________________
__________________________________________________________________________________________________________
National Insurance No: ______________________________________
Position Applied for: ________________________________________
Are you currently working? YES/NO If yes please give details______________________________________________________
Emergency Contact Details
Next Of Kin ________________________________________ Relationship: ______________________________________
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Home Tel: _________________________________________ Mobile: __________________________________________
Passport No:_________________________________ Passport Date of Issue:_________________________________
Passport Expiry Date:____________________________
Professional Registration Details
Name of professional body (e.g. MNC, HPC, AODP :) _________________________________________________-
Registration /Membership Grade/No: ______________________________ Expiry Date____________________
Part of Register:__________________________ Registration/ PIN Number: _________________________
Expiry Date:_______________________________
Speciality Codes/ ENB qualifications: ________________________________________________
Health Details
Name of G.P _________________________________________ Tel: ____________________________________________
Address: __________________________________________________________________________________________________
__________________________________________________________________________________________________________
Have you attended a doctor in the past 12 months? YES/NO
If yes, please give details_____________________________________________________________________________________
Please answer the following questions by ticking the appropriate column (YES/NO) and if yes give details and date.
Do you or have ever suffered from any of the following YES NO Details/ Date
1. Asthma, Bronchitis, Pleurisy?
2. Heart/Circulatory Trouble /Raised Blood Pressure?
3. Back trouble causing time off work?
4. Black out/Epilepsy/fainting Attacks/Giddiness?
5. Nervous/Mental Disorders/Stress related disorders?
6. Any serious illness?
7. Are you diabetic?
8. Are you a registered disabled person?
9. Have you had a recent chest x-ray?
10. Have you got any allergic condition e.g. Dermatitis
due to latex gloves?
11. Have you stayed away from work due to illness in the
past years?
12. Are you on medication at present?
13. Have been abroad recently for certain periods of
time?
IMMUNISATIONS
14. Have you a T.B Test?
15. Have you had BCG vaccinations?
16. Have you been immunised against poliomyetis?
17. Have you had German measles antibody test?
18. Have you had Hepatitis B & C vaccinations? ( full
course)?
Any information supplied by you on this form will be held in secure files
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BANK DETAILS
Name of Bank/Building Society: ____________________________________
Address: __________________________________________________________________________________________________
Post Code: _______________________
Account Number: __________________________________________________ Sort Code: _______________________________
EDUCATION AND TRAINING
Name and Address of Course/Subject Taken From (Month/Year) To (Month/Year)
School/ College/University
State any work related courses including the mandatory training.
Organisation Course Qualification Achieved/ Date
Working towards
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EMPLOYMENT HISTORY
Present/Most recent employer and address Position Held From (Month/Year) To (Month/Year)
(include any voluntary work)
Please provide the names of 2 references, one of which should be your recent employer.
1) 2)
Name: ________________________________ Name: ________________________________
Address: ______________________________ Address: ______________________________
______________________________________ ______________________________________
______________________________________ ______________________________________
______________________________________ ______________________________________
Occupation: ___________________________ Occupation: ___________________________
Tel: __________________________________ Tel: __________________________________
It is Liberty Care’s policy to obtain a disclosure from the Criminal records Bureau (CRB) for all successful applicants. However, a
criminal record will not necessarily be a bar to obtaining a position.
Do you agree to allow us to undertake a Criminal Records Bureau check? YES____ NO ______
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DECLARATION
I hereby authorise Liberty Care Employment Ltd and present/ past employers to give my information that may be sought
concerning this application regarding my work, character and skills. I understand and agree to passing on of references once I have
accepted the employment to a future employer.
I ………………………………………………………… further agree to treat as confidential any information received concerning
the business of LCEL or its clients and not to disclose such information in any way or other than as directed by LCEL in
accordance with the company policy. I understand LCEL operates an equal opportunity policy, which means that it will not
discriminate directly or indirectly, against people on grounds of sex, race, colour, age or disability. It will not discriminate in
training services and every vacancy will be open to those with appropriate qualifications.
I confirm that the information given true.
Signed…………………………………………………… Date …………………..
Rehabilitation of Offender Act 1974
The post for which you are applying is exempt from section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of
rehabilitation of offenders Act (Exemption Order) 1975. It’s therefore in anyway contrary to the Act to reveal any information you
may have concerning convictions which would be considered as “spent” in relation to this application, and which you consider
relevant to the applicants suitability for employment.
Any such information will be kept in the strictest confidence, and only used in consideration of this applicant for the position where
such an exemption is appropriate.
Have you had any convictions, whether or not considered spent? YES/NO
If yes, please give details in a separate sheet.
I declare that the information given on this form is true, complete and correct to the best of my knowledge.
Signed: _______________________________________ Date: ___________________
EMPLOYEE’S LEVEL OF COMPETENCE
Please tick in accordance with your level of expertise
ACTIVITY POOR AVERAGE GOOD VERY GOOD
PERSONAL
HYGIENE
BATH/WASH
DRESSING
TOILETING
FEEDING
CATHETER
HANDLING
AVAILABILITY SCHEDULE
Employee’s Name: _____________________________
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Available Start Date: ____________________________
DAY 700-1400 1400-2100 2100-700
EARLY LATE NIGHT
SHIFT SHIFT SHIFT
MONDAY
TUESDAY
WEDNESSDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
EVERY WEEKEND ALTERNATIVE EVERY THIRD
WEEKENDS WEEKEND
SATURDAY
SUNDAY
Your working times will be chosen considering the above.
However, the company will or can call you to request whether you can cover any shift out side your available times.
This availability schedule can only be altered by giving four weeks notice, please ask for another schedule to complete in this case.
Employee’s signature: __________________________________ Date: ________________________
OTHER INFORMATION
The Commission for Racial Equality recommends the categories used in the 1991 census as follows; they are about colour or broad
ethnic group-UK citizens can belong to any of the groups indicated;
1. Are you? Male/ Female
2. Are you? Married/ Single/ Separated/ Divorced
3. I would describe my ethnic origin as:
Black African (including UK)
Black Caribbean (including UK)
Black Other (please specify) ___________________
Bangladeshi (including UK)
Chinese/Vietnamese
Indian (Including UK)
Pakistan (including UK)
White
Other (please specify) _______________________
Please describe yourself in your own words, skills, abilities knowledge and experience, which you possess that are relevant to your
job. (Please continue to another separate sheet if needed)
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Please return your completed application form with:
2 recent passport photographs.
2 copies of your passport/Work Permit Status.
Copies of relevant certificates of courses done.
CRB check( not less than 3 months old)
LIBERTY CARE EMPLOYMENT LTD
WORKING TIME REGULATIONS ACT 1998
Waiver Declaration:
I _____________________________________(PRINT NAME), hereby waive my legal rights, under “the working time regulations
Act 1998” and request ______________________________________________ (NAME OF AGENCY) to work in excess of 48
hours per week averaged over the number of weeks I am employed on a particular contract. I undertake to inform Liberty Care
Employment Ltd if I take up other employment or jobs whilst still at Liberty Care which may affect my standard of performance
and create a conflict of interest.
If I wish to change the amount of hours I work per week then I must give it in writing to my employer- Liberty care employment at
least a month’s notice.
Signed: ________________________________________
Print name: _____________________________________ Date: __________________________________________
