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Your Details

To & From (Month & Year)

Academic Qualifications

Please include the institute/location of study, type of qualification and the dates of study (to and from - MM/YY)

Professional & Clinical Qualifications

Please include the institute/location of study, type of qualification and the dates of study (to and from - MM/YY)

Current Employment

Please provide their name, address and contact details

Full Employment History

Please provide the company name, position held, start and end date and your reason for leaving. Please also detail any gaps in employment.

Community, Volunteer or Intern Experience

Please provide the company name, position held, start and end date and your general duties.

Permissions to work in the UK

Evidence to be provided and a copy taken.

Skills & Experience

References

Please provide full names and addresses of two professional employment referees covering between 5-10 years employment history and one character referee. Your first reference must be from your current or previous last place of work and addressed to your line manager. Lone Care Services Ltd cannot use friends or relatives for any employment references. Employment references cannot be sent to private or personal home addresses. You must provide workplace addresses and the referee must be a higher grade of staff than you yourself i.e. your line manager.

Next of Kin Details

Disclosure & Barring Services Check

(whether related to work or not)

Disclosure & Barring Services Disclaimer

You are not exempt from the provisions of the Rehabilitation of Offenders Act 1974, you are not therefore entitled to withhold information requested by the company about any previous convictions in this country or abroad you may have, even if in other circumstances these would appear spent. I confirm that the information I have given is true. I understand that if information given on the application form is found to be false it may result in disciplinary action which could include dismissal. Should I be offered employment, I accept that I will be required to notify the company of any changes to my DBS status.

The European Union has laid down guidelines for all workers, governing the length of the maximum working week that is safe to work. The current limit is 48 hours per week. Because you are under no obligation to accept work offered, you will not be compelled to work more than 48 hours per week, however you may choose to do so. Please tick the appropriate box to confirm that you have read and understood the above information.

Experience Checklist

Personal Care

Specialist Care

Mobility Support

Nutrition

Practical Support

Practical Support

Additional

Specialist

Misc Exp

Other

Health Declaration

Health Assessment

Please give reasons
If Yes, please answer the following questions in the space at the end of the form: Are you having any problems at present? Does your condition cause symptoms that are particularly troublesome i.e. short of breath, wheezing, coughing bouts? When did you last have an attack?
If "yes" does this affect your physical stamina in any way?
If "yes", is it under control and your blood sugar stable? Does it require treatment with insulin injections on a strict timetable?
Please give details of times and what medication you take.

Vaccinations

It may be a requirement of any assignment that you have a Hepatitis B vaccination. Restrictions may apply if you do not have a current certificate of vaccination.

Equality & Diversity

Race Relations (Amendment) Act 2000

(please tick relevant box below)

Employment Equality Regulations 2003

Please select the option which best describes your sexuality

Disability Discrimination Act 1995

People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark 'other'.

Religion