Lumina Staffing
Application Form
Personal Information
Title:
Mr
Mrs
Miss
Other
Full Name:
*
First Name
Middle Name
Last Name
Date of Birth:
*
Please select a month
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Year
Gender:
*
Male
Female
Other
What is your Nationality?
Email Address:
*
example@example.com
Phone Number:
*
Format: (000) 000-0000.
Do you have a valid UK driving licence?
Yes
No
Do you have your own reliable vehicle?
National Insurance Number:
*
Do you have a valid passport?
Yes
No
Passport Number:
In what country was your passport issued?
Do you have a visa/residence permit which allows you to work in the UK?
*
Yes
No
Immigration Status:
*
Full UK Citizen(UK Passport Holder/British Birth Certificate)
Indefinite Leave to Remain
Tier 2 Sponsorship Visa
Student Visa
Dependent Visa
Asylum Visa
Home Office Letter
Limited Leave Visa
Other
Are you restricted to working 20 hours per week?
Yes
No
Are you a European National?
Yes
No
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of
Experience
What healthcare settings you have worked in within the United Kingdom?
Care Home
Nursing Home
Mental Health/Support Work
Home care
Supported Living
Hospital
How long have you been working in the United Kingdom Healthcare industry?
Education & Qualifications
Education:
High School
Under Graduate
Post Graduate
Other
Emergency Contact Details
Next of Kin: (Please fill in below details of your next of kin)
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
2 Year Address History
Address 1 (Previous Address) :
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Move In Date:
*
-
Month
-
Day
Year
Date
Move Out Date:
*
-
Month
-
Day
Year
Date
Address 2 (Current Address):
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Move In Date:
*
-
Month
-
Day
Year
Date
Employment History
Kindly provide a detailed record of your employment over the past two years, starting with your most recent position. In case the space provided is insufficient, please submit the information in a separate word document. Additionally, kindly explain any periods of time without employment.
Company Name:
*
Job Role:
*
Date Of Joining:
*
-
Month
-
Day
Year
Date
Date Of Leaving:
*
-
Month
-
Day
Year
Date
Are you currently still employed with this organization? If no please state your reason for leaving:
Company:
Job Role:
Date Of Joining:
-
Month
-
Day
Year
Date
Date Of Leaving:
-
Month
-
Day
Year
Date
Are you currently still employed with this organization? If no please state your reason for leaving:
Professional References
Kindly provide two professional references from your most recent employment, ideally dated within the past six months. These references must be from within the UK healthcare industry and should come from official business email addresses (not personal email accounts).
Reference 1:
Please fill in below details of your first referee.
Company:
*
Name of Supervisor:
*
Supervisor Job Title:
*
Email:
*
example@example.com
Reference 2:
Please fill in below details of your second referee.
Company:
*
Name of Supervisor:
*
Supervisor Job Title:
*
Email:
*
example@example.com
Criminal Record Check
If the role you're applying for (whether paid or voluntary) falls under Schedule 1, Part II of the Rehabilitation of Offenders Act (Exceptions) Order 1975, we reserve the right to pose Exempted Questions, as defined by Section 113(5) of the Police Act 1997, regarding your background. For positions involving Care Managers or Care Workers, we are obligated to conduct a DBS Certificate check through the update system. Should your application progress successfully and prior to finalizing your appointment, you will be requested to furnish a current and valid personal DBS Certificate for our review. It's important to note that possessing a criminal record may not automatically disqualify you from employment with us. Any such determinations will be contingent upon the nature of the role and the specifics of your past offenses. We adhere to the 'Code of Practice for Registered Persons and Other Recipients of Disclosure Information,' issued by the Disclosure & Barring Service on behalf of the Home Office. Upon request, we are happy to provide you with a copy of this code. This applies for a PVG too.
It is your duty to report any arrest or investigations which have occurred or are pending:
*
I understand it is my responsibility to inform Lumina Staffing of any current or pending changes in the status of my DBS or PVG
Do you have a DBS on the Update Service?
*
Yes
No
Other
DBS or PVG Certificate Number:
*
Date of Issue:
*
-
Month
-
Day
Year
Date
We do not apply for criminal record checks, your DBS must be on the update service or your DBS must be valid/in date and be updated every 12 months.
*
I understand
Are you happy for us to check the online status of your DBS and PVG?
*
Yes
No
Convictions
Do you have any prior convictions, cautions, reprimands, or final warnings on your record?
*
Yes
No
Right To Live And Work
Do you have the right to live and work in the UK?
Yes
No
Medical Questionnaires
Do you have any illness/impairment/disability (physical or psychological) which may affect your work?
*
Yes
No
Are you pregnant?
*
Yes
No
Are you on any medication that may affect your work?
*
Yes
No
Are you having, or waiting for treatment (including medication) or investigations at present?
*
Yes
No
Please disclose if you have any medical conditions that have not been mentioned above:
Declaration:
*
I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.
Signature
*
Timesheets & Payments
Submitting Timesheets:
Please ensure that your timesheet is accurately completed. It is crucial to include your full name and signature, client name, client signature, week starting date (the Monday in which you work), hours worked and break time. Please note that, under UK law, employees are entitled to rest breaks. According to the Working Time Regulations 1998, workers are entitled to a 20-minute break for every 6 hours worked and 1 hour break for a 12-hour shift. If the break section on your timesheet is left blank and no client authorization as to why no break was taken, the legally required break time will be deducted from your timesheet. Please note Failure to provide this information will result in non-payment as your timesheet is your only valid receipt of work and this is non-negotiable. Take a clear photograph of your timesheet, capturing all four corners and ensuring legible writing, including both your signature and the client's signature (nurse, manager, senior staff). Timesheets must be submitted on a Monday before 11:00am, you can submit your timesheet by sending it through on the email provided - bookings@luminastaffing.co.uk. Timesheets that are late or not filled out correctly will not be processed for payment and will be delayed until we receive a completed and signed timesheet.
I acknowledge the requirement to submit my timesheet for each working week (from Monday to Sunday) by the 11:00 am deadline every Monday to ensure timely payment. I comprehend that without a correctly completed timesheet signed by an authorized representative at my assigned placement; I will not receive payment. Recognizing that timesheets serve as evidence of work, I commit to submitting them before the agreed-upon deadline. I also understand that any falsification of timesheets could result in repayment of funds to the client and potential legal consequences against me.
*
I accept the terms and conditions
Signature
*
How Payments Are Made:
Our payment schedule operates on a bi-weekly basis. This means that each week worked is compensated two weeks later. Payments are typically processed within 14 working days, with disbursement occurring on Fridays. In the event that a payday coincides with a bank holiday, payments maybe issued earlier or later as necessary. You will be contacted to complete an HMRC new starter form before you are paid so that we can assign the correct tax code. You will be paid via PAYE. Please note that the rates quoted are inclusive of holiday pay per hour, so the total amount paid will match the rate quoted. If you wish to opt out of the pension scheme, you will need to do so directly with NEST Pensions and inform us. We only accept UK bank accounts in the applicant’s name. We do not accept joint accounts. Your banking information will be requested during the registration process. After completing your first shift with us, we will order your Lumina Staffing branded uniform based on the size and address you provide during the compliance process. The cost of the uniform is £17.50, including delivery, and this amount will be deducted from your pay. This deduction is non-negotiable, and wearing the uniform while on assignment is mandatory to maintain a professional and consistent appearance inline with our company standards. If you would like to order an additional uniform, please let us know and we will arrange this for you. You must be fully compliant with Lumina Staffing before any payment can be processed. This includes completing all mandatory training and any other requirements requested by Lumina Staffing as part of the onboarding and compliance process. All compliance must be completed by Wednesday at 2:00 PM in the week you are due payment; otherwise, payment will be delayed.
Declaration:
*
I understand that Lumina Staffing makes payments on a bi-weekly(two weeks) basis and agree to be paid in this manner and adhere to all compliance required of me.
I understand that the bank statement I provide during the recruitment and compliance process is the one that will be used to receive my pay
Signature
*
New Employment
Should the opportunity arise that one of the clients that we send you to would like to offer you a job opportunity or you would like to apply to work directly with them, you will need to make the agency aware of the agreement before accepting or before you apply. By signing below, you acknowledge and consent to the terms outlined above.
Signature
*
Working Time Regulations 1998
The European Union has laid down guidelines for all workers, governing the length of the maximum workingweek that is safe to work.
The existing limit is set at 48 hours per week. While you are not obligated to accept offered work, you will not be required to work beyond 45 hours per week. However, you have the option to do so if you wish.
*
I accept the terms and conditions
Terms & Conditions
Confidentiality:
You are expected to maintain confidentiality regarding all information encountered or shared during your duties. Any data considered commercially sensitive to the organization or that could jeopardize client privacy or security must not be disclosed. This encompasses, but is not restricted to, personal information, client addresses, private or business activities, services rendered, and associated fees.
*
I accept the terms and conditions
I acknowledge that Lumina Staffing reserves the right to share pertinent details regarding DBS or PVG checks and professional registration with relevant third parties. It is understood that this information will not be retained for marketing purposes.
*
I accept the terms and conditions
I agree to promptly notify Lumina Staffing of any changes that may affect my status, and I acknowledge that the information provided on this form will be electronically processed and utilized for registration purposes, in compliance with the Data Protection Act. Additionally, I understand that regulatory bodies like the Care Quality Commission and third parties may inspect any personal data held by Lumina Staffing as part of their audit protocols.
*
I accept the terms and conditions
I confirm that I agree to comply with all Lumina Staffing Limited policies, procedures, and professional standards at all times while representing or working through the agency.I understand that it is my responsibility to read and familiarise myself with these policies. I acknowledge that it is my responsibility to request copies from Lumina Staffing Limited before undertaking work.
*
I accept the terms and conditions
Date Processing:
Personal information provided on this declaration will be processed and stored in strict adherence to the Data Protection Act 1998 and the General Data Protection Regulation 2018.Lumina Staffing ensures that all files are securely maintained in a safe and protected environment in compliance with applicable legislation.You acknowledge that any personal details held by Lumina Staffing may be accessed periodically by inspectors from regulatory bodies and authorized individuals as per contractual obligations.
*
I accept the terms and conditions
I confirm that I have thoroughly read this document and that all provided information is accurate to the best of my knowledge and belief.
*
I confirm
Full Name:
*
First Name
Last Name
Date:
*
-
Month
-
Day
Year
Date
Signature:
*
Submit
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