Apply - Lea Care

New Application Form (1)

Please complete this form in full using BLOCK CAPITALS.

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SECTION 1: PERSONAL DETAILS
Name*
Title First Name Middle Name Last Name
Have you ever been known by any other names? (e.g. Christian/maiden/have you changed your name by deed poll) ?*
- Yes
- No
If Yes, please state ALL names by which you have previously been known by (you may be required to provide proof of name change if so)
Place of birth*
Nationality*
Languages spoken (indicate fluency)
Language Fluency
Address
Your Current Address*
Street Address City State / Province / Region ZIP / Postal Code
Email*
All contact telephone numbers*
Next of Kin/Emergency contact details (phone number/address/relationship)*
Do you hold a current valid UK driving licence?*
- Yes
- No
Please state your mode of transport*
If you are required to use your car for work purposes, you will be required to have business class 2 insurance.
Therefore, we will require a copy of your driving licence and insurance certificate.

Read and sign:
•I confirm I do not have any health issues that could affect my ability to drive
•I confirm that my business class 2 is up to date and will be renewed yearly
•I confirm that I carry out regular safety checks (tyres, lights, wipers, oil, water etc on my vehicle).
Signature*
Date*
MM slash DD slash YYYY
Are you currently working?
- Yes
- No
Position*
Notice period*
Reason for leaving*
How did you hear of LEA Care Ltd?
SECTION 2: SECURITY AND RIGHT TO WORK IN THE UK
Are you eligible to work in the United Kingdom?*
- Yes
- No
Do you require a visa to work in the United Kingdom?*
- Yes
- No
If yes, what type of visa do you hold?
Type
Visa no.
Expiry date
UK entry date
NI number
In line with Home Office guidance on the prevention of illegal working we will need to verify and take a copy of your original ID documentation as evidence of your right to work in the UK if you are to be engaged by LEA Care Ltd for temporary work.
Do you have any spent or unspent* criminal convictions?*
- Yes
- No
Are you currently under investigation and/or do you have any previous convictions including any cautions, reprimands, final warnings, bind-overs or any convictions from overseas that are not ‘protected’ under the Rehabilitation or Offenders Act 1974 (Exceptions) Order 1975, as amended in 2013?*
- Yes
- No
*Certain types of employment and professions are exempt from the Rehabilitation of Offenders act 1974 and in those cases, particularly where the employment is sought in relation to positions involving working with children or vulnerable adults, details for all criminal convictions must be given. The information given will be treated in the strictest of confidence and only taken into account where, in the reasonable opinion of City Force Health Care Ltd, the offence is relevant to the position of agency nurse. Failure to declare a conviction may require us to exclude you from our register or terminate an assignment if the offence is not declared but later comes to light.
Due to the nature of our business, you are required to submit a DBS check. Do you agree for an enhanced DBS check to be carried out?*
- Yes
- No
Rehabilitation of Offenders Act 1974 (Exception) Order 1975, as amended in 2013 and the Disclosure of Criminal Convictions*
- Yes
- No
The position that you are applying for has been identified as exempt under the Rehabilitation of Offenders Act (1974) (Exceptions) Order 1975, as amended in 2013 (“the Act”). Applicants are therefore required to disclose information about any convictions, cautions (including reprimands and final warnings provided they are not ‘protected’. Note: The amendments to the Act mean that certain convictions and cautions are now ‘protected’ and do not, therefore, have to be disclosed. Please see separate Guidance for details.
Please give details below
Date Offence Conviction/Caution Fine/Community Service Order/Prison Sentence
A criminal record will not necessarily preclude you from our register. Offences will be considered according to the nature and circumstances of the offence, length of time ago and type of work for which you are applying. All circumstances will be taken into account; however, inconsistencies compared with the information given above may invalidate your application. Once accepted on to our register our clients also need to consider your conviction information to assess whether it precludes you from the specific position for which you are proposed. We may require you to provide a statement detailing the circumstances surrounding any conviction information you have supplied. Criminal record information will always be shared confidentially and at an appropriate level. Please ask if you would like a copy of our Employing Ex-offender’s policy or the Disclosure & Barring Service Code of Practice or Disclosure Scotland Codes of Practice.

Please read and sign the below:
- I confirm that I have read and understood the above information relating to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, as amended in 2013, and have declared all relevant information.
- I hereby consent to my DBS Check/Disclosure Scotland and its contents being disclosed to any prospective employers.
- I will inform LEA Care LTD immediately, should I be convicted of an offence or cautioned in the future.
- I hereby give consent to a DBS Check/Disclosure Scotland check.
Signature*
Date*
MM slash DD slash YYYY
Overseas Candidates Police Check Information
If you are an overseas applicant who has entered the UK in the last 5 years you must obtain an original police check from your country of origin. All overseas applicants will also require a DBS Check/Disclosure Scotland.
SECTION 3: HEALTH & SAFETY
Do you require any reasonable adjustments to be made/special facilities to be provided to enable you to attend any interview, assessment or work placement?*
- Yes
- No
If Yes, please provide details.
Own insurance*
- Yes
- No
Name of insurance provider
Policy number
Expiry date
MM slash DD slash YYYY
Insurance provided by membership to relevant Organisation or Union?*
- Yes
- No
Name of Organisation or Union
Expiry date
MM slash DD slash YYYY
SECTION 4: EDUCATION & QUALIFICATIONS, TRAINING, PROFESSIONAL REGISTRATIONS & WORK HISTORY
Original certificates will need to be presented at interview. Please note evidence of training is required for agency files. LEA Care Ltd requires mandatory training according to the areas in which you require work. All training is provided by appropriately qualified instructors and is provided from the cost of £60 to all agency members. Appraisals and training reviews are regularly offered to all agency workers.
EDUCATION & QUALIFICATIONS*
School/College/University Dates to/from Course title or subject Qualification gained
TRAINING*
Course title & Provider Date Attended Other details
PROFESSIONAL REGISTRATIONS*
Profession Specialty Registration Number Type i.e. GMC, NMC, HCPC, SSSC, CCW, GDC, GPHC Expiry Date

All professional memberships will be verified with the relevant professional body.
WORK HISTORY (Please print clearly details of the past five years work history. Most recent first)*
Employer Address Position Held Dates to/from Reason for leaving

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, Schedule 3 states that LEA Care Ltd are required to gain a full work history CV from the date you left compulsory education. All employment gaps should be explained.
SECTION 5: REFERENCES
Please supply the names and contact details for a minimum of two referees. One of these must be from your current or most recent place of employment. References will only be accepted from your direct line manager or HR department. By providing details below you are granting permission for us to apply for your references. Please ensure these cover the last 3 years.
REFERENCES*
Name Organisation Job Title Unit/Ward Address Telephone number Email Address Length of time known to you Dates employed (to/from)
SECTION 6: EQUAL OPPORTUNITIES
LEA Care Ltd is committed to a policy of equal opportunities for all work seekers and shall adhere to such a policy at all times and will review on an on-going basis on all aspects of recruitment to unlawful or undesirable discrimination. We will treat everyone equally irrespective of sex, sexual orientation, marital status, age, disability, race, colour, ethnic or national origin, religion, political beliefs or membership or non-membership of a trade union and we place an obligation upon all staff to respect and act in accordance with the policy. LEA Care Ltd shall not discriminate unlawfully when deciding which candidate/temporary worker is submitted for a vacancy or assignment, or in any terms of employment or terms of engagement for temporary workers. LEA Care Ltd will ensure that each candidate is assessed only in accordance with the candidate’s merits, qualification and ability to perform the relevant duties required by a particular vacancy.
Gender
Nationality
Disability
The Disability Discrimination Act 1995 defines a person as having a disability if he/she has a Physical or Mental impairment which has a substantial and long-term adverse effect on his/her ability to carry out normal day-to-day activities.
Do you have a disability as defined above?*
- Yes
- No
If the above does not apply to you, but you do consider yourself to have a disability then please tick here
Please detail any other equal opportunities information that you would like to mention (e.g. sexual orientation, religion).
SECTION 7: DECLARATION
Professional misconduct, disciplinary action and investigations
Have you ever been the subject of professional misconduct proceedings or disciplinary action from an employer?*
- Yes
- No
Are you aware of any investigation or grievance being undertaken by an organisation following allegations made against you?*
- Yes
- No
Have you been referred to the Disclosure and Barring Service (DBS) or any other organisation or list barring you from working with children and/or vulnerable adults?*
- Yes
- No
If you have answered yes to ANY of the above, please provide details including the name of the employer, the date, the allegation and the outcome. Where appropriate please also include the name of the licensing or regulatory body concerned.
I declare that, if in the future, I am subject to any misconduct proceedings, disciplinary action or am suspended from duty or involved in an investigation by any other employer or agency I will inform LEA CARE LTD immediately.
Signature
Date*
MM slash DD slash YYYY
APPLICATION
I confirm that any information I have provided is truthful and accurate to the best of my knowledge. I have not withheld any information that could affect my future employment. Prior to engagement of work with LEA Care Ltd, right to work check is carried out as part of the agency registration process, verification of any professional qualifications and in the case of temporary assignments, subject to satisfactory references. We will use the information you provide us in accordance within the General Data Protection Regulations (GDPR) 2018.

I will inform LEA Care Ltd immediately of any circumstances that may affect my work, such as changes to any requirements for reasonable adjustment to be made to enable me to attend an interview or assessment, or subsequent pending prosecutions or convictions, disciplinary or professional misconduct proceedings and involvement in work related investigations which may arise whilst I am participating in the recruitment process for permanent work and/or whilst I am registered for temporary work.

I understand that my registration or work placement can be terminated at any time following unsatisfactory work reports.

Your file may be subject to audit or inspection by an external body. This may include medical information and/or immunisation histories/certificates.
Signature*
Date*
MM slash DD slash YYYY

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TRAINING COST
Each working candidate is required to hold mandatory training as a minimum. Mandatory training must be full and comprehensive and be in date by a maximum of one year. Any mandatory training completed over one year ago must be renewed prior to engagement. If you are without full, in-date mandatory training, you can source this yourself but it must be to an acceptably high standard and you must be able to provide an original training certificate to the agency for your file prior to engagement. Alternatively, LEA Care Ltd is able to provide mandatory training. We can book either 1 day refresher training for the cost of £60 or £100 for the cost of 2 days Care Certificate training. This cost should be paid prior to being booked and can be in cash or via bank transfer. In some instances, LEA Care Ltd may cover the cost for you and arrange a re-payment plan. In this instance a plan will be agreed, and you will be asked to sign a training payment agreement. In the event that you fail to attend training that has been paid for by LEA Care Ltd, having previously agreeing to attend, you will be subject to a non- attendance charge of £60 or £100.00 depending on the training number of days booked.

By signing below, you agree to the above training costs terms.
DBS COST
Each working candidate is required to be in possession of a current, enhanced DBS check prior to engagement. If you do not hold a current enhanced DBS check, we are able to run one on your behalf at a cost of £75.00 and should be paid in advance. In some instances, LEA Care Ltd may cover the cost for you and arrange a re-payment plan. In this instance a plan will be agreed, and you will be asked to sign a DBS payment agreement.

By signing below, you agree to the above DBS costs terms.
CODE OF CONDUCT FOR HEALTHCARE / SUPPORT WORKERS IN ENGLAND (Including Registered Nurses)
To ensure that we are confident you are aware of your responsibilities and accountabilities as a health care worker or nurse. Please sign below to acknowledge you have read and understood the Code of Conduct for Healthcare Support Workers and Adult Social Care Workers in England.
UNIFORM COST
Upon engagement with LEA Care Ltd you will be issued with a branded uniform which must be worn at all times when on site (unless you are working at a site that does not require a uniform). The cost of each branded uniform is £25 which must be paid for upon collection. Dependent upon the frequency of your shifts with us you will be required to possess an adequate number of uniforms to ensure that you are always able to wear a clean one for work. In line with Infection control protocol candidates must not wear their uniform on the way to work or on the way home from work.

By signing below you agree to the above uniform costs and terms.
Signature*
Date*
MM slash DD slash YYYY

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REGISTRATION DECLARATIONS
APPLICATION AND CONDUCT
I declare that I have completed the LEA Care Ltd application pack, and all answers and information provided by myself is true and accurate to the best of my knowledge.
I confirm that I will comply with policies and procedures of the hospital or organisation in which I am engaged as a temporary worker.

COMPLAINTS
If a complaint is raised against yourself whilst engaged by LEA Care Ltd, or any other agency or employer, I will inform LEA Care Ltd immediately.

SECURITY
I confirm that I am aware that the trust/organisation where I attend assignments have the right to carry out any physical searches of me, my possessions and my vehicle while on the premises. Any person, firm or organisation who is responsible to the trust/organisation for security matters shall, when carrying out such searches, comply with the Human Rights Act 1998.

FITNESS TO PRACTICE
I agree to inform LEA Care Ltd immediately if I am the subject of any pending prosecution, work related investigation, disciplinary action or professional misconduct proceedings by any other organisation or if there are changes to my personal circumstances that could affect my fitness to practice as a healthcare professional.

PERMISSION TO CARRY OUT EMPLOYMENT CHECKS
I give LEA Care Ltd permission to carry out relevant Employment Checks, including external checks on my qualifications, a media check and agree to these checks, other personal data and records being shared with the trust/organisation for validation, verification, inspection and audit purposes.

DECLARING HEALTH AND HYGIENE
I confirm that when I attend an assignment that I will be in good health, medically and physically fit. If not, I will inform LEA Care Ltd as soon as I can before I attend my shift. I will also ensure that my standard of oral and personal hygiene is acceptable.

I confirm that I have read the above declarations and understand that I must abide by their content
Signature*
Date*
MM slash DD slash YYYY

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New Application Form (1)

Step 1 of 7

SECTION 1: PERSONAL DETAILS

Address

SECTION 2: SECURITY AND RIGHT TO WORK IN THE UK

SECTION 3: HEALTH & SAFETY

SECTION 4: EDUCATION & QUALIFICATIONS, TRAINING, PROFESSIONAL REGISTRATIONS & WORK HISTORY

SECTION 5: REFERENCES

SECTION 6: EQUAL OPPORTUNITIES

Disability

SECTION 7: DECLARATION

APPLICATION

Health questionnaire to assess if you are fit to work nights.

Health Conditions

HCA Skills Check List

Payment Information

TRAINING COST

DBS COST

CODE OF CONDUCT FOR HEALTHCARE / SUPPORT WORKERS IN ENGLAND (Including Registered Nurses)

UNIFORM COST

REGISTRATION DECLARATIONS

GDPR Compliant Consent Form for Candidates

Copyright © 2024 LEA Care, All rights reserved.

Language	Fluency

Date	Offence	Conviction/Caution	Fine/Community Service Order/Prison Sentence

School/College/University	Dates to/from	Course title or subject	Qualification gained

Course title & Provider	Date Attended	Other details