Application Form

Thank you for choosing Lanbeth Resolutions Limited!

Our application form has been made as easy as possible to complete; however,
should you have any issues please contact us and we’ll guide you through. Once
you have completed the form please have it uploaded and attach all documents
as required and send to our email: info@lanbethresolutions.co.uk. We’ll be in
touch to schedule an interview with you.

About You

Title

First Name

Middle Name

Last Name

Previous Names if any

Gender

Date of Birth

National Insurance
Number
Home Phone No

Mobile Number

Email address

Home Address

Post Code
Proof of Address
Please send as attachment any two of the items stating your full name and current
home address

Documents we will accept

 Utility bill (gas, electric, satellite television, landline phone bill) issued within the
last three months

 Local authority council tax bill for the current council tax year

 Bank, Building Society or Credit Union statement or passbook dated within the
last three months

 Original mortgage statement from a recognised lender issued for the last full year

 Solicitors letter within the last three months confirming recent house purchase or
land registry confirmation of address

 Council or housing association rent card or tenancy agreement for the current
year

 HMRC correspondence within the current financial year (e.g. P45 / P60, self-
assessment letter, tax demand, etc.)

- Do you have any Dependents? (Children) (yes or No):

- Where did you hear about us? :

- How long have you worked in Health / Social Care? :

- Which of the Following Health / Social Care Settings have you worked in? Please
you may select from the list hereunder:

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d
1. PICU & Acute Psychiatric Hospital Units

2. Child & Adolescent (CAMHS) Mental Health Services

3. Secure Forensic Psychiatric Hospital Units

4. High Dependency Psychiatric Hospital Units (HDUs)

5. Long-Term Mental Health Rehabilitation Hospital Units

6. Brain Injury / Neuro Rehabilitation Hospital Units

7. Eating Disorders

8. Personality Disorders

9. Substance Misuse

10. Learning / Intellectual Disabilities

11. Autistic Spectrum Disorders

12. Epilepsy and Related Disabilities

13. Physical Disabilities

14. Residential Homes

15. Supported Living Services

16. Day Centres

17. Children’s Homes

18. Specialist Schools / Education Facilities

19. Community Outreach Services

20. Drug & Alcohol Services

21. Family Support Services

22. Homeless Services (e.g. Shelters, Hostels)

23 Ex-Offender Services

24 Refuges (domestic violence)

Position Applied for:

Equal Opportunities Monitoring Form

Lanbeth Resolutions Ltd appoints employees on merit, and does not discriminate, act
unfairly or unlawfully in recruitment or employment process. We believe that our
workforce should reflect local and wider community.

All information provided will be treated as confidential and will be used solely by the
Lanbeth Resolutions Ltd for the purposes of equal opportunities monitoring to assist us
in ensuring that people are selected, promoted and treated on the basis of their abilities.
This monitoring form does not form part of your application or the short listing process
and will be detached on receipt and stored separately.

What is your Tick as appropriate:

Ethnic Group?
White Dual Heritage Asian or Asian British Black or Black
British Prefer not to say

Other Ethnic
Groups:
Next of Kin

First Name

Last Name

Relationship

Phone
Right to Work in the UK

Nationality:

Do you have any Right to Work in the UK restrictions? (Yes/No):

Do you have a visa or permit? (Yes/No):

Employment / Training / Education History

Position Held / Status

Organisation / School

Date from

Date to

Brief description of
your duties and
responsibilities.

Position Held / Status

Organisation / School

Date from

Date to
Brief description of
your duties and
responsibilities.

Position Held / Status

Organisation / School

Date from

Date to

Brief description of
your duties and
responsibilities.

Position Held / Status

Organisation / School

Date from
Date to

Brief description of
your duties and
responsibilities.

Position Held / Status

Organisation / School

Date from

Date to

Brief description of
your duties and
responsibilities.

Position Held / Status

Organisation / School

Date from

Date to

Brief description of
your duties and
responsibilities.

Higher Education

Please attach proof of any relevant higher education / qualifications (e.g. Nursing
Degree Certificate, Psychology Degree or NVQs in Social Care etc.)
References

Please provide details of two people from whom we can obtain references covering the
past three years, starting with your most recent employment.

Please inform your referee that you are putting their name forward, and check that the
e-mail address and phone number you are providing are correct.

If during the past 3 years you have not been in employment, please provide details of
someone who can provider a character reference (e.g. a teacher or tutor). A character
reference must not be from a relative or someone who has a financial arrangement with
you.

Referee 1

Name

Company

Job Title

Phone

Email address

Work Reference
(Yes/No)
Was this referee your
line manager?
(Yes/No)
If ‘Yes’ please give
dates
Start Date

End Date

Referee 2

Name
Company

Job Title

Phone

Email address

Work Reference
(Yes/No)
Was this referee your
line manager?
(Yes/No)
If ‘Yes’ please give
dates
Start Date

End Date

I ………………………………………………………………… confirm that the above

references cover the last 3 years and I have checked that the referees are prepared to
provide references to Lanbeth Resolutions Ltd.

Disclosure and Barring Service

All candidates will be required to have an enhanced DBS unless registered with the
Update service

Have you had a DBS check? (Yes/No):

Type of Disclosure (Standard/Enhanced)

DBS Issued Date,

Reference Number

Are you on the Update Service (Yes/No):

Please attach Copy of DBS Certificate

Rehabilitation of Offenders

All posts involving direct contact with vulnerable children or adults are exempt from the
Rehabilitation of Offenders Act 1974. The amendments to the Exceptions Order 1975
(2013) provide that certain spent convictions and cautions are "protected". These are
not subject to disclosure to employers and cannot be taken into account. Guidance and
criteria on the filtering of these cautions and convictions can be found on the Disclosure
and Barring Service website.

Have you ever been convicted of a criminal offence which is not

'protected'? (Yes/No):
If you have answered yes, please supply full details of all convictions:

If your application is successful, this information will be checked against information

received from the Disclosure and Barring Service before your appointment is
confirmed.

Protection of Children and Vulnerable Adults Declaration

Has any Social Service Department or Police Service ever conducted an enquiry or
investigation into any allegations or concerns that you may pose an actual or potential
risk to children or vulnerable adults? (Yes / No):

Have you ever been convicted of any offence relating to children or vulnerable adults?
(Yes / No):

Have you ever been the subject of any disciplinary procedure or been asked to
leave employment or voluntary activity due to inappropriate behaviour towards a child or
vulnerable adult? (Yes / No):

If yes to any of these questions please give details below.

Signature: (type your name as signature)

Date:

Training
Mandatory Care Training (Yes / No)
PMVA (Prevention and Management of Violence and Aggression) (Yes / No):

Safeguarding Level 3 (Adults & Children) (Yes / No):

Immediate Life Support (Yes / No):

I ………………………………………............................... understand that I must at all

times, avoid moving and handling any person or object which may put my physical
health or the clients well-being at risk required , I understand that I must at all times,
avoid moving and handling any person or object which may put my physical health or
the clients well-being at risk is required.

Health Declaration
Do you have any illness/impairment/disability (physical or psychological) which may
affect your work? , Do you have any illness/impairment/disability (physical or
psychological) which may affect your work? ( Yes/No):

Do you have any illness/impairment/disability (physical or psychological) which may

affect your work? (Yes/No):

Have you ever had any illness/impairment/disability which may have been caused or
made worse by your work (Yes/No):

Are you having, or waiting for treatment (including medication) or investigations at

present? (Yes/No):

If your answer is yes, please provide further details of the condition, treatment and
dates

Do you think you may need any adjustments or assistance to help you to do the job?
(Yes/No):

Immunisation
(Type Yes or No)

Rubella Yes / No

Tetanus Yes / No

Tuberculosis Yes / No

Hep B Yes / No

Polio Yes / No

Covid-19 Risk Assessment

During the current COVID-19 pandemic, we are required to check if you have any
underlying conditions or identified risk factor(s) that may put you at increased risk in the
workplace.

Do you have a shielding letter, shielding condition or vulnerable

condition? (Yes/No)
Liver Disease (Yes/No)

Organ Transplant (Yes/No)

English Language Competency

Lanbeth Resolutions Ltd is legally obliged to ensure our support workers have the
required level of English language competency to deliver adequate support for our
young people.

Are you a British Citizen / UK VISA Holder / national from a majority English speaking
country? (Yes/No)

Bank Details
Will you be working as 'Pay As You Earn' or paid through a Umbrella Company?
(PAYE / Umbrella)

Sort Code: ………………………………………………….

Account Number: ………………………………………….

I authorise Lanbeth Resolutions Ltd to pay my weekly earnings directly into the bank or
building society whose details I have given above. I confirm that I will notify Lanbeth
Resolutions Ltd in writing of any changes of these details.

Terms of Engagement – Your Contract with Lanbeth Resolutions Ltd.

I agree to Lanbeth Resolutions Ltd Terms of Engagement for:

Full Name: ……………………………….

Date: ………………………………………

Working Time Regulations

The Working Time Regulations 1998 state that you are unable to work in excess of an
average of 48 hours per week (calculated over a 17 week period) unless agreed with
Lanbeth Resolutions that this limit should not apply.

Lanbeth Resolutions wishes to have an agreement with you, which will apply until
terminated by notice whereby:

1. The average 48 hour work limit will not apply to you.

2. This agreement may be terminated by yourself by giving Lanbeth Resolutions Ltd
7 days written notice.

If you accept this proposal please sign below by typing your name.

Full Name: ………………………………………………….

Your Personal Data

Lanbeth Resolutions provides work-finding services to its clients and work-seekers. We
must process personal data (including sensitive personal data) so that we can provide
these services – in doing so, we act as a data controller. We process your personal data
in accordance with data protection laws. These laws require us to give you a Privacy
Statement to explain how we manage your personal data.

I ………………………………………………………………. consent to my personal data

being processed by Lanbeth Resolutions Ltd.

Final Declaration

I ………………………………………………… confirm that the information given within

this form is true and accurate and I understand that failure to disclose any relevant
information or providing false or inaccurate information may be regarded as a breach of
any subsequent contract Lanbeth Resolutions Ltd, resulting in disciplinary action and /
or dismissal.

I …………………………………………………. understand that my registration with

Lanbeth Resolutions Ltd is subject to the completion of background checks, including
satisfactory references and an enhanced DBS check.

Signature ………………………………………

Declaration Date: ……………………………..

Thank you for taking the time to complete our Application Form!
Before you send as attachment to our email, please check that you have
completed all the required sections, attach all required documents,
and read and understood the Professional Codes, our Terms of Engagement and
signed the declaration.