Application Form LCG

Application Form
THE INFORMATION YOU SUPPLY ON THIS FORM WILL BE TREATED IN CONFIDENCE.

A hard copy will be retained, and a copy will be kept on a computer database.
Position applied for*
Full Name*

PrefixFirst NamesLast Names
Available to Start Date*

DayMonthYear
Date
Date of Birth*

DayMonthYear
Date
Place of Birth*
Address*
Postcode*
E-mail*
Telephone*
Are you eligible to work in the UK?*

YesNo
National Insurance number
Do you hold a full driving license?*

YesNo
If yes, detail points or convictions*
points or convictions
Languages Spoken*

EnglishPolishPunjabiUrduBengaliGujaratiArabicFrenchChinese languagesPortugueseSpanishItalianRussianGermanDutchBSLOther
Marital Status*

Common Law Partnership DivorcedMarried/Civil Partnership SingleDivorcedWidowedSingleOther
How were you referred to us?

Walk-inEmployeeNHSFacebookIndeedInternetOther
Section 2 - Safeguarding

Ex-Offenders Declaration

Please note this section will only be seen by those involved in the recruitment process and will be treated with the strictest of confidence.

Rehabilitation of Offenders Act 1974

Lifecome Limited T/A Lifecome Care aims to promote equality of opportunity and is committed to treating all applicants fairly regardless of ethnicity, disability, age, gender or gender reassignment, religion or belief, sexual orientation, pregnancy or maternity, and marriage or civil partnership. Lifecome Limited T/A Lifecome Care undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared.

Answering 'yes' to the questions below will not necessarily prevent your employment. This will depend on the relevance of the information you provide in respect of the nature of the position and the particular circumstances.
1. Are you currently bound over or do you have any current UNSPENT convictions that have been issued by a Court or Court-Martial in the United Kingdom or in any other country?*

YesNo
If yes, please, comment
2. Do you have any current UNSPENT police cautions, reprimands or final warnings in the United Kingdom or in any other country?*

YesNo
If yes, please, comment
Section 3 - Education, Job Skills & Training

Please, enter where and when you completed your studies. Leave no gaps between the end of studies and start of employment. For example, if you did not work but were looking after a family member, went abroad, etc. It is important to have a full picture of your history.
Education

Name the last school, course and date completed.
School/College/Universiy*
Location*
Course*
Level*
Start Date

DayMonthYear
Date
End Date*

DayMonthYear
Date
Skills - Describe your skills relevant to position you are applying:*
Employment History

Full employment history must start immediately after school ends. If you did not start working straight away or stopped working for some period, declare what you were doing (i.e. gap year, looking after a family member, etc.)
From the date you last complete studies until reaching the present date, leave no time gaps without detailing.
Employer/Activity*
Role*
Location*
Start Date

DayMonthYear
Date
End Date*

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Training and/or Certifications
Upload you CV

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Do you need more Employment History Fields?

YesNo
Employer/Activity*
Role*
Location*
Start Date

DayMonthYear
Date
End Date*

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Do you need more Employment History Fields?

YesNo
Employer/Activity*
Role*
Location*
Start Date

DayMonthYear
Date
End Date*

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Employer/Activity
Role
Location
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Section 4 - Experience

Tick as appropriate, this can be life experience or work experience

General*

	None	Little	Some	Plenty
Residential
Nursing
Dementia
Brain Injury
End of Life
Learning Disabilities
Hospital Environment
Mental health
Physical Disabilities
Support work

Mobility*

	None	Little	Some	Plenty
Moving and Handling
Use of hoist
Walking aids
Slide sheets/transfer aids
Wheelchair
Transfer

Food and Drinks*

	None	Little	Some	Plenty
Food hygiene regs
Meal preparation
Snacks

Toileting*

	None	Little	Some	Plenty
Catheter bags
Colostomy bags
Bed Pans
Commodes

Observations*

	None	Little	Some	Plenty
Blood Pressure
Pulse
Temperature

Health and Safety*

	None	Little	Some	Plenty
Risk assessment
COSHH
RIDDOR

Domestic*

	None	Litle	Some	Plenty
Housework
Laundry
Bed making
Shopping
Bills payment
Handling money
Ironing
Washing up
Care of pets
Home maintenance
Light gardening

Section 5 - References

Please give details of your two most recent employers. If you are unable to do this, please clearly outline who your referees are.
Reference 1*
Company Name
Full Name of referee
Position
E mail Address example@example.com
Telephone Number
Full Address
Reference 2*
Company Name
Full Name of referee
Position
E mail Address example@example.com
Telephone Number
Full Address
Section 6

Equal Opportunities Monitoring

Lifecome Limited T/A Lifecome Care is committed to equality of opportunity and fair treatment in all aspects of employment. We aim to provide a working and learning environment that is free from unfair discrimination and will enable staff to fulfill their personal potential. The information you provide will be treated as strictly confidential in line with the Data Protection Act 2018 and will be used only for equal opportunities monitoring. It will help us to comply with the law under the relevant Acts and to ensure that our employment policies and practices are fair and effective.

IMPORTANT - Please Note: You do not have to complete this section. The information is given on a voluntary basis and the information provided will only be used for the monitoring purpose. Your information remains confidential. This will be stored on a computer.
As per Equality Act 2010 - Under the terms of the Act a disability is defined as a “physical or mental impairment which has a substantial and long-term effect on a person’s ability to carry out day-to-day activities”.
Ethnic Origin

AsianBlackMixed originWhiteGypsyIrish TravellerHispanic OriginI do not wish to discloseOther
Gender

FemaleMaleTransgender FemaleTransgender maleNon-binaryI do not wish to discloseOther
Sexual Orientation

HeterosexualGayLesbianBisexualI do not wish to discloseOther
Religion or Belief

BuddhistJewishChristianMuslimHinduSikhSpiritualistI do not wish to discloseNoneOther
Do you consider yourself to have a Disability?

YesNoI do not wish to disclose whether or not I have a disability
Caring Responsibilities - Do you have any care responsibilities for anyone?

YesNo
If yes to above, are they:

Children under 16DisabledSick or ElderlyOther
Section 7

DBS / Update Service
By submitting/signing this form I give permission to Lifecome Care to complete an update check on my most recent DBS.*

YesDo not have a current DBS
If you do not have a current DBS then a full enhanced DBS will need to be completed and by marking this I give permission for the Yes full enhanced DBS to be completed on my behalf, at the cost of £67.00.*

YesOther
Details of DBS to check
DBS Certificate Number
MonthDayYear
DBS issue date
Name on DBS
MonthDayYear
Date of birth
Checklist
You are required to provide evidence of the above details at your interview by bringing with you:*

Proof of eligibility to work in the UK (Passport/ Visa etc.)Driving License & Counterpart if applicablePhoto ID CardProof of NI numberProof of address (dated within last 3 months)Dates of any name changes2 x references (1 from your most recent employer, 1 from your next most recent employer)Past 5 years of address (including postcode, mm/yy of moving in and out of address)Complete CV from high school to date, all gaps explained
Your documents – as you go through your checklist above, documents can be uploaded already and, original copies will need to be seen at your interview

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Referees will be contacted to verify the references given. An overseas Police Check/ Criminal Records Disclosure (for overseas candidates only All documents must be translated into English where applicable.
Privacy

Following UK's Data Protection Regulation (GDPR), Lifecome Limited T/A Lifecome Care will only collect data for specified, explicit and legitimate use in relation to the recruitment process. By submitting this application form, you consent to Lifecome Limited T/A Lifecome Care holding the information contained within this application form. If successfully shortlisted, data will also include shortlisting scoring and interview records. We would like to keep this data until the vacancy is filled. We are required to keep this information within the candidate's personnel file. We cannot estimate the exact time period it will be held for. When that period is over, we will delete your data. We have privacy policies that you can request for further information. You have a right for your data to be forgotten, to rectify or access data, to restrict processing, to withdraw consent, and to be kept informed about the processing of your data. When not in use, we will either delete your data or inform you that we would like to keep it in our database for future roles.

We have privacy policies that you can request for further information. Please be assured that your data will be securely stored and only used for the purposes of recruiting for this vacant post. If you would like to discuss this further or withdraw your consent at any time, please contact the Registered Manager or Quality & Compliance Administrator on 020 3393 7048.

Declaration

In submitting (signing), I declare that the information in this application form is true and complete.

I agree that any deliberate omission, falsification, or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed by Lifecome Limited T/A Lifecome Care.

Where applicable, I consent that Lifecome Limited T/A Lifecome Care can seek clarification regarding professional registration details.
Name*
Date*

DayMonthYear
Date
Signed*

Clear
Lifecome Care - 128B Brixton Hill, London, SW2 1RS. Tel: 020 3393 7048
Should be Empty:

Application Form

Section 2 - Safeguarding

Ex-Offenders Declaration

Rehabilitation of Offenders Act 1974

Section 3 - Education, Job Skills & Training

Education

Employment History

Section 4 - Experience

Section 5 - References

Equal Opportunities Monitoring

DBS / Update Service

Checklist

Privacy

Declaration