Online Registration

Application Form

Application to join us

Thank you for your interest in joining our team at LOGIC CARE SOLUTIONS Ltd. Please complete all
sections and return it with all supporting documents to the above address.

If you would like to additionally attach a CV, please do. If you need any help, please call us on 01634
321967 or email info@logiccaresolutions.co.uk.

Which position are you applying for (please tick one)?

I am applying as a registered nurse (RGN). My current PIN number is given below.

I am applying as a registered nurse (RMN). My current PIN number is given below

I am applying as a Healthcare Assistant (HCA).

I am applying as a Support Worker.

For nurses only, what is your NMC PIN number?

Please tell us a bit about you

Title

Surname

Surname at birth (if different)?

Middle name

First name

Please tell us a bit more

What is your nationality?

What is your date of birth?

Place of birth?

Town

Country:

What is your current address?

What is your mobile telephone number?

Alternative number (if applicable)?

What is your e-mail address?

Personal details

What is your national insurance number?

Do you hold a full & valid UK driving license?

Yes

Do you normally have access to a car to get you to/from work?

Yes

How did you hear about LOGIC CARE SOLUTIONS Ltd.?

If it was through someone who already works with us, please enter that person’s name.

Bank details

How would you like to be paid?

PAYE

Direct through UTR or the company below

If you do, which type of permit do you have?
(e.g. work permit, biometric residence, dependent etc.)

If applicable, what is your unique tax reference (UTR) or company name?

Your eligibility to work in the UK

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

Yes

No (please skip to next section)

Staff paid through PAYE and earning over the qualifying amount per
fortnight are automatically enrolled into our workplace pension.

How many hours per week are you permitted to work? ☐

Unlimited

This no. hours:

Please provide a copy of this permit along with this application form.

Training & Education

Was your mandatory training - for example moving & handling, infection control, safeguarding, medication admin (RNs only) completed within the last year ?

yes

Briefly outline any qualifications as well as professional & vocational training that you feel are relevant to this job

Employment History

Briefly detail your employment history within the past 5 years, starting with the most recent. Please include details of any employment gaps within this period. You can add a separate sheet if needed.

Employment details

Name of the company

Reason for leaving

Date from

Date to

Previous Convictions

Please give details of any convictions in this country or abroad you currently or have previously had.
If none, please write the word “NONE” in this box. Please be aware that it is an offence to withhold this information.

References

Please give details of two people that would be prepared to give you a reference. One must be from a current/previous employer; the other should be a character reference, from someone other than a family member. Any offer of employment will be subject to satisfactory references. By entering their details here, you give LOGIC CARE SOLUTIONS Ltd. permission to contact these people.

Reference 1 – Professional reference, from a senior colleague who has worked with you

Professional references must cover the last five years of work. If this reference does not cover this period, please provide additional referee details separately. If you were studying, you may provide a contact at your school/college to cover this period of education.

Name:

Position:

Organisation & address:

Contact number:

Email address:

Reference 2 – Character reference, from someone who knows you well but is not a family member

Name:

Address:

Contact number:

Email address:

Emergency contact

Please give contact information for ONE PERSON we could contact on your behalf in an emergency. These details are held by LOGIC CARE SOLUTIONS Ltd. and only given to the relevant parties in the event of an emergency. Where possible, please give a UK mobile number.

Contact Name & phone number

Address:

Relationship to you:

DBS status

As part of your application we must determine your current DBS status. We can do this through the DBS Update
service or by requesting a new certificate for you.

Have you subscribed for the DBS Update Service?

Yes

No (please skip to next section)

Please enter the number of the DBS certificate you
subscribe with?

Please note this is the DBS certificate number, not your subscription number.

Working Preferences & Working Time Regulations

When would you prefer to work? (circle all that apply)

Day Shifts

Night Shifts

Weekdays

Weekends

Briefly give details of any other employment you currently have – either full or part time

Night shift working (if you may wish to work nights)

Have you worked night shifts before?

Yes

Have you ever suffered from health problems working night shifts? ☐ Yes ☐ No ☐ Yes ☐ No If so, please give details…

Yes

When working night shifts, are you able to able to sleep in the day without incurring any health problems?

Yes

Health & Safety

Do you have a disability of any kind that may affect your work? ☐ Yes ☐ No If so, please give details …

Yes

Do you have any special needs or medical conditions that others, ☐ Yes ☐ No including clients, may need to be aware of in an emergency? If so, please give details …

Yes

Do you have any allergies or religious beliefs that prevent you working with specific foods? If so, please give details…

Yes

Online data

We keep many of your records securely online. In addition, clients may ask that these
are uploaded and shared online with their own client base (e.g. nursing & care homes),
prior to the commencement of your first shift with them

Do you authorise that these details can be shared with them online?

Yes

Working time regulations

Under European Union rules, the maximum working week is currently limited to 48 hours. As you are under no obligation to accept any work offered, you will not be compelled to work more than 48 hours per week. However, you may choose to do so.

I DO NOT wish to work more than 48 hours per week

I DO wish to work more than 48 hours per week

Documents we will need to see

As part of your application we will need to see copies of the following documents. You can send some or all of these
now, later or during your interview though the sooner we have them the faster we can process your application.

Please do not send originals by post; any original documents we need to see (marked * below) can be brought to
your interview.

Proof of ID If you subscribe to the DBS Update service…
• Your main passport page *
• 1 x proof of address (recent utility bill, bank statement, council tax etc.)
If you do not subscribe to the DBS Update service…
• Your main passport page *
• 2 x proof of address (recent utility bill, bank statement, council tax etc.)
Right to work Proof of your right to work in the UK…
• Your main passport page *
• Your Biometric Residence Permit (BRP)* if applicable
• Any visa or residence permit *
• Any appropriate Home Office letter or supporting documentation *
DBS If you subscribe to the DBS Update service…
A copy of the original DBS certificate used by the Update service
If you do not subscribe to the DBS Update service, we will need to request a new
certificate in order to verify your current DBS status.
Training If you have completed any mandatory training within the past year, please provide
proof.
Qualifications If applicable, please send proof of any relevant medical or care-based qualifications
you have – e.g. NVQ, QFC, diploma, degree etc.

Data Protection

Our records, including any copies of documents supplied are kept securely in line with GDPR regulations. You
understand & give permission for these to be made available from time to time to authorised personnel or
inspectors.
Home Office Immigration Check
If applicable, you understand & give permission for LOGIC CARE SOLUTIONS Ltd.to contact the appropriate
authority in order to verify your current immigration status.

Declaration

I confirmthatI have readand understood theabove and confirm my answersto be accurate
and correct.
Additionally, I understand that …

It is my responsibility to update LOGIC CARE SOLUTIONS LTD in the event any of these
details change in the future.
Any job offer made to me is based on a zero-hours contract with noguarantee of work
or workinghours.
Any job offer made to me is subject to satisfactory references being obtained from the
individuals offered above. I give permission for LOGIC CARE SOLUTIONS LTD to contact
referees given.
Upon acceptance, if I do not subscribe to the DBS Update Service, LOGIC CARE SOLUTIONS Ltd
will arrange a Disclosure and Barring Service (DBS) check now, and at intervals
thereafter. I agree to pay the cost of this, determined at the time, either through
deductions from my wages, or paid directly by me after three months from the DBS
request being made, whichever issooner.
I also understand that LOGIC CARE SOLUTIONS LTD may contact the Home Office/UK
immigration in order to verify my eligibility to work in the UK.
If informationgiven on this applicationform isfound to be false it may resultin
disciplinary action, or dismissal.

Signed: Full name: