Private and Confidential

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. The last page of this form is designed to enable us to monitor our equal opportunities policy. The information, which you provide, will be treated in the strictest of confidence and will not be used in any way when assessing your suitability to work with us.

Personal Details




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 you 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 is leading 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

If you have been, or currently working for an Agency, it is your responsibility to heck with the Agency that you are available to work for Local Care Direct 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.