Application Form

Position Applied for

Reference Number

Personal Details

Title

Forename(s)

Surname

Address

Tel No. (Home)

Tel No. (Mobile)

N.I Number

Current Driving Licence

Do you have a valid Driver's licence?

Yes

Groups:

Expiry Date

Employment Restrictions

Are there any restrictions on you taking up Employment in the UK?

Yes

If yes, Please provide details

Education

Please Name your places of Education and the Qualifications gained.

Leisure

Please note here your leisure interests, sports and hobbies, other pastimes, etc.:

Employment History

Last/Current Employer

Name of Employer

Address

Dates of Employment

Job Title

Duties

Rate of Pay

Reason for Leaving

Notice Period

Previous Employment #2

Name of Employer

Address

Dates of Employment

Job Title

Duties

Rate of Pay

Reason for Leaving

Previous Employment #3

Name of Employer

Address

Dates of Employment

Job Title

Duties

Rate of Pay

Reason for Leaving

Other Employment

Please note any other employment that you would continue with if you were to be successful in obtaining the position:

Current Membership of Professional bodies (i.e. CIPD, NMC)

Please note any professional bodies you are a member or registered with:

References

(please note here four persons from whom we may obtain both character and work references)

Reference #1

Title

Forename(s):

Surname

Address

Contact Number

Position Held

May we approach the above prior to interview?

Yes

Reference #2

Title

Forename(s):

Surname

Address

Contact Number

Position Held

May we approach the above prior to interview?

Yes

Reference #3

Title

Forename(s):

Surname

Address

Contact Number

Position Held

May we approach the above prior to interview?

Yes

Reference #4

Title

Forename(s):

Surname

Address

Contact Number

Position Held

May we approach the above prior to interview?

Yes

General Comments

Please detail here your reasons for this application, your main achievements to date and the strengths you would bring to this post. Specifically, please detail how your knowledge, skills and experiences meet the requirements of this role (as summarised in the person specification).

Criminal Record

Please note any criminal convictions except those 'spent' under the Rehabilitation of Offenders Act 1974. If none please state. In certain circumstances employment is dependent upon obtaining a satisfactory Disclosure & Barring Certificate from the Disclosure & Barring Service/Disclosure Scotland.

Data Protection

1. We are aware of our obligations under data protection legislation, including the obligation to collect only the data
that is required for our specific purpose. The information collected in this application form is specific to our
recruitment exercise and necessary for the performance of the role that you have applied for. If you are recruited for
the role you have applied for, or any other role you are offered by us, the information provided will then be used for
the purposes of your employment with us, together with further information collected upon recruitment for those
purposes.

2. We will treat all personal information about you with utmost integrity and confidentiality. Our data protection policy
sets out our approach to ensuring that your data is processed in line with the data protection principles within current
data protection legislation.

3. Our privacy notice for job applicants gives you information on, amongst other things, the data we will hold about
you during the recruitment exercise and what we use it for. Delete as applicable - A copy of the privacy notice is
attached to this application form / You can view the privacy notice at (insert web address).

Declaration (please read this carefully before signing this application)

1. I confirm that the information provided in this application is complete and correct and that any untrue or misleading information will give my employer the right to terminate any employment contract offered.

2. Should we require further information and wish to contact your doctor with a view to obtaining a medical report, the law requires us to inform you of our intention and obtain your permission prior to contacting your doctor. I agree that the organisation reserves the right to require me to undergo a medical examination.

3. I agree that should I be successful in this application, I will, if required, apply to the Disclosure & Barring Service/Disclosure Scotland for a Disclosure & Barring Certificate. I understand that should I fail to do so, or should the disclosure not be to the satisfaction of the company any offer of employment may be withdrawn or my employment terminated.

Signed:

Date

48 HOUR OPT OUT AGREEMENT

This Agreement is made between

Luu-Bridgets Healthcare Limited

Room 212

Island Business Centre

18-36 Wellington Street

Woolwich

SE18 6PF

(the company)

and

The Working Time Regulations 1998 provide that the average working week, including overtime, shall not
exceed 48 hours. The Company and the Worker agree that this limit shall not apply to the Worker. This
Agreement will remain in force indefinitely. The Worker, or the Company, may terminate this Agreement
at any time by giving not less than three months’ written notice to the other.

Signature of Worker

Name of Worker (Print)

Date

Signature On behalf of Luu-Bridgets Healthcare Limited

Name (Print)

Date

Equal Opportunity Monitoring

We are an equal opportunity employer. The aim of our policy is to ensure that no job applicant or employee
receives less favourable treatment because of age, disability, gender reassignment, marriage and civil
partnership, pregnancy or maternity, race, religion or belief, sex or sexual orientation.

Our recruitment selection criteria and procedures (including the areas or media sources which are used in
the recruitment process) are frequently reviewed to ensure that individuals are selected, promoted and
treated on the basis of their relevant merits and abilities and that no applicant or employee is disadvantaged by provisions, criteria or practices which cannot be shown to be justified.

To ensure that this policy is fully and fairly implemented and monitored, and for no other reason, would you please provide the following information:

I would describe my sex and ethnic group as:
(Please tick one box for your sex and one box for your ethnic group)

Sex:

Male

Female

Prefer Not To Say

Ethnicity

Chinese, Chinese British, Chinese English, Chinese Scottish or Chinese Welsh

Chinese

Other Ethnicity (please specify)

Prefer not to say

Signature

Date

Print Name

Health Questionnaire

If the answer is yes to any of the questions on this form, please give full details in the space provided of
the dates, duration and outcome of the illness or condition. If we have any concerns about your fitness for
work, employment will be subject to satisfactory medical reports.

Application Form

Personal Details

Current Driving Licence

Employment Restrictions

Education

Leisure

Employment History

Last/Current Employer

Previous Employment #2

Previous Employment #3

Other Employment

Current Membership of Professional bodies (i.e. CIPD, NMC)

References

Reference #1

Reference #2

Reference #3

Reference #4

General Comments

Criminal Record

Data Protection

Declaration (please read this carefully before signing this application)

48 HOUR OPT OUT AGREEMENT

Equal Opportunity Monitoring

Health Questionnaire

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