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.

Professional Details

Please upload your copies of the following:
  1. CCTGP - Certificates of completed training
  2. PMETB - Postgraduate Medical Education & Training Board
  3. JCPTGP - Joint Committee on postgraduate training for general practice

MDU/MPS/MDDUS/Other (Please Specify)


NOTE: By virtue of the Rehabilitation of Offenders Act 1974, Section 4(2) of the Rehabilitation of Offenders Act 1974 does not apply to this question. You are therefore not entitled to withhold information about a previous conviction on the grounds that it is for other purposes spent under the Act.


(One of which should be your current or most recent employer)


(Please read carefully, then sign and date your application)
I confirm that the information I have provided is correct and understand that misleading statements may be sufficient grounds for cancelling any agreements made. I also understand that questions left unanswered may be discussed at interview(s) arising from this application.

 Agency Declaration

(Please read carefully, then sign and date)
If you have been, or currently working for an Agency, it is your responsibility to check with the Agency that you are available to work for Local Care Direct directly and that LCD will not incur any financial penalties. If financial penalties are incurred they will be your responsibility to cover. I acknowledge the content of the above declaration and agree to its terms.

Compliance Documents

Please upload include copies of the following:
  • Proof to work in UK (eg: UK Passport)
  • Safeguarding Children Level 3 (Within last 3 years)
  • Safeguarding Adults Level 2 (Within last 3 years)
  • Mental Capacity Act 2005 Certificate (Within last 3 years)
  • Basic Life Support/ CPR (Within last 12 months)
  • Prevent Training Certificate (Mandatory for those responsible for safeguarding level 3 within the next 3 years)
  • Proof of Covid Vaccination (approved evidence as per government guidelines)
Thank you