Clinical Bank Workforce Application Form

We are having technical issues with our forms. Please complete an email with the information below and send directly to HR@lcdwestyorks.nhs.uk

Please accept our apologies for any difficulties this may cause you.

APPLICATION TO JOIN LOCAL CARE DIRECT’S
CLINICAL BANK WORKFORCE

Your privacy

The information provided on this form will help us to assess your suitability to work with Local Care Direct. Please answer the questions fully and complete clearly. All information will be treated in strictest confidence.

Do you have any friends or relatives currently working for Local Care Direct?

If yes, please provide their name(s) and relationship(s):

Have you worked for Local Care Direct before?

If yes, please provide dates, location and position:

Have you worked for Local Care Direct before through an agency?

If yes, please tell us when and the agency:

Please tell us if there are any dates when you will not be available for an interview:

Personal Details

Your name

First

Last

Your home address

Your contact address (if different from home)

Your home phone No

Your mobile phone No*

Your email address*

Your NI number

Do you require a work permit to be employed in the UK?

Are you able to demonstrate eligibility to work in the UK?

If you are invited to attend an interview you will be required bring evidence of your eligibility to work in the UK (e.g. Passport, NI Card, Work Permit)

Please note that this role will include operating in patient facing clinical environments. From 1st April 2022, those in patient facing roles are required by law to provide evidence of double vaccination for Covid-19 or medical exemption as per current government requirements.

Professional Details

Which role are you applying for?

Please upload your CV:

Please ensure your CV details your education, training and your employment history, including your current employer.

Please provide details of any gaps in your employment over the last five years:

What is your Smartcard UUID number?

Who is your registering body:

What is your registration number:

Please write a cover letter below detailing why you would like to join LCD's clinical workforce bank and what interests you about the role. Please also provide examples of the things you have done that demonstrate how you have the relevant skills and experiences.

References

Please provide two references (one of which should be your current or most recent employer). We will only approach your current employer when you have given us permission to do so or you have accepted our offer of employment.

1st Referee's: name

1st Referee's: what is your relationship with this referee

1st Referee's: Tel. No.

1st Referee's: email address

1st Referee's: address

2nd Referee's: name

2nd Referee's: what is your relationship with this referee

2nd Referee's: Tel. No.

2nd Referee's: email address

2nd Referee's: address

Disclosure & Barring Service

If you are successful in being offered the job with LCD a criminal records check will be carried out. Please complete the declaration below:

If required to complete a criminal records application form, I can state that to the best of my knowledge and belief, there will not be a positive disclosure made that will preclude me from working with vulnerable adults and children. I also give permission for a copy of the disclosure to which I am subject, being made available to a named Authorised Person upon written request, who acts on behalf of a National Government department for auditing purposes.

Applicant's digital signature

Date

Rehabilitation of Offenders Act 1974

Under the Act, most sentences by a Court for criminal offences may be regarded as Spent and Disregarded, for most purposes, after a specified period of time and need not then be disclosed. However, the appointment for which you have applied is one to which the Rehabilitation of Offenders Act (Exceptions) Orders apply. You are therefore required to declare any criminal convictions, including cautions, reprimands and final warnings. Enquiries and checks may be made in this respect.

Have you ever appeared in court and been sentenced, this includes convictions and absolute or conditional discharge for an offence (including motoring but not parking offences) or are any charges or summons at present outstanding against you?

If YES please give details:

Please give details of any hearings pending:

Failure to disclose any convictions, including ‘spent’ convictions, cautions, reprimands or final warnings, may result in any offer of employment being withdrawn or disciplinary action being taken which may lead to dismissal.

Declaration

Please read your application carefully, then sign and date to confirm that it is true to the best of your knowledge.

I can confirm, that to the best of my knowledge, the information I have detailed on this application form is a true statement of myself. I accept that by providing deliberately false information it will result in the withdrawal of an offer, or if my employment has started, my dismissal from LCD.

Applicant's digital signature*

Date*

This field should be left blank