1. Title *
2. First Name(s) *

1. Has your first name changed since birth? * —Please choose an option—YesNo

1. If yes, when was it changed?

1. Birth First Name(s)
2. Surname(s) *
3. Has your surname changed since birth? * —Please choose an option—YesNo
4. If yes, when was it changed?
5. Birth Surname(s)
6. Mother's Maiden Name *
7. Gender * —Please choose an option—MaleFemale
8. National Insurance Number *
9. Date of Birth *
10. Birth Nationality * —Please choose an option—AfghanAlbanianAlgerianAmericanAndorranAngolanAnguillanArgentineArmenianAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBenineseBermudianBhutaneseBolivianBotswananBrazilianBritishBritish Virgin IslanderBruneianBulgarianBurkinanBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCayman IslanderCentral AfricanChadianChileanChineseCitizen of Antigua and BarbudaCitizen of Bosnia and HerzegovinaCitizen of Guinea-BissauCitizen of KiribatiCitizen of SeychellesCitizen of the Dominican RepublicCitizen of VanuatuColombianComoranCongolese (Congo)Congolese (DRC)Cook IslanderCosta RicanCroatianCubanCymraesCymroCypriotCzechDanishDjiboutianDominicanDutchEast TimoreseEcuadoreanEgyptianEmiratiEnglishEquatorial GuineanEritreanEstonianEthiopianFaroeseFijianFilipinoFinnishFrenchGaboneseGambianGeorgianGermanGhanaianGibraltarianGreekGreenlandicGrenadianGuamanianGuatemalanGuineanGuyaneseHaitianHonduranHong KongerHungarianIcelandicIndianIndonesianIranianIraqiIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhKenyanKittitianKosovanKuwaitiKyrgyzLaoLatvianLebaneseLiberianLibyanLiechtenstein citizenLithuanianLuxembourgerMacaneseMacedonianMalagasyMalawianMalaysianMaldivianMalianMalteseMarshalleseMartiniquaisMauritanianMauritianMexicanMicronesianMoldovanMonegasqueMongolianMontenegrinMontserratianMoroccanMosothoMozambicanNamibianNauruanNepaleseNew ZealanderNicaraguanNigerianNigerienNiueanNorth KoreanNorthern IrishNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New GuineanParaguayanPeruvianPitcairn IslanderPolishPortuguesePrydeinigPuerto RicanQatariRomanianRussianRwandanSalvadoreanSammarineseSamoanSao TomeanSaudi ArabianScottishSenegaleseSerbianSierra LeoneanSingaporeanSlovakSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSouth SudaneseSpanishSri LankanSt HelenianSt LucianStatelessSudaneseSurinameseSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTogoleseTonganTrinidadianTristanianTunisianTurkishTurkmenTurks and Caicos IslanderTuvaluanUgandanUkrainianUruguayanUzbekVatican citizenVenezuelanVietnameseVincentianWallisianWelshYemeniZambianZimbabwean
11. Town of Birth *
12. Country of Birth * —Please choose an option—AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArmeniaArubaAustraliaAustriaAzerbaijanAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia and HerzegovinaBotswanaBouvet Island (Bouvetoya)BrazilBritish Indian Ocean Territory (Chagos Archipelago)British Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuraçaoCyprusCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKazakhstanKenyaKiribatiKoreaKoreaKuwaitKyrgyz RepublicLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsMexicoNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Netherlands)Slovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & S. Sandwich IslandsSpainSri LankaSudanSurinameSvalbard & Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUnited KingdomUnited StatesU.S. Virgin IslandsU.S. Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe
13. Has your nationality changed since birth? * —Please choose an option—YesNo
14. If yes, what is your new nationality? —Please choose an option—AfghanAlbanianAlgerianAmericanAndorranAngolanAnguillanArgentineArmenianAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBenineseBermudianBhutaneseBolivianBotswananBrazilianBritishBritish Virgin IslanderBruneianBulgarianBurkinanBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCayman IslanderCentral AfricanChadianChileanChineseCitizen of Antigua and BarbudaCitizen of Bosnia and HerzegovinaCitizen of Guinea-BissauCitizen of KiribatiCitizen of SeychellesCitizen of the Dominican RepublicCitizen of VanuatuColombianComoranCongolese (Congo)Congolese (DRC)Cook IslanderCosta RicanCroatianCubanCymraesCymroCypriotCzechDanishDjiboutianDominicanDutchEast TimoreseEcuadoreanEgyptianEmiratiEnglishEquatorial GuineanEritreanEstonianEthiopianFaroeseFijianFilipinoFinnishFrenchGaboneseGambianGeorgianGermanGhanaianGibraltarianGreekGreenlandicGrenadianGuamanianGuatemalanGuineanGuyaneseHaitianHonduranHong KongerHungarianIcelandicIndianIndonesianIranianIraqiIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhKenyanKittitianKosovanKuwaitiKyrgyzLaoLatvianLebaneseLiberianLibyanLiechtenstein citizenLithuanianLuxembourgerMacaneseMacedonianMalagasyMalawianMalaysianMaldivianMalianMalteseMarshalleseMartiniquaisMauritanianMauritianMexicanMicronesianMoldovanMonegasqueMongolianMontenegrinMontserratianMoroccanMosothoMozambicanNamibianNauruanNepaleseNew ZealanderNicaraguanNigerianNigerienNiueanNorth KoreanNorthern IrishNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New GuineanParaguayanPeruvianPitcairn IslanderPolishPortuguesePrydeinigPuerto RicanQatariRomanianRussianRwandanSalvadoreanSammarineseSamoanSao TomeanSaudi ArabianScottishSenegaleseSerbianSierra LeoneanSingaporeanSlovakSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSouth SudaneseSpanishSri LankanSt HelenianSt LucianStatelessSudaneseSurinameseSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTogoleseTonganTrinidadianTristanianTunisianTurkishTurkmenTurks and Caicos IslanderTuvaluanUgandanUkrainianUruguayanUzbekVatican citizenVenezuelanVietnameseVincentianWallisianWelshYemeniZambianZimbabwean
15. Mobile Phone Number *
16. Home Phone Number
17. Email *

1. Address Line 1 *
2. Address Line 2
3. Town/City *
4. County * —Please choose an option—AberdeenshireAngusArgyllAvonAyrshireBanffshireBedfordshireBerkshireBerwickshireBuckinghamshireCaithnessCambridgeshireCheshireClackmannanshireClevelandClwydCornwallCounty AntrimCounty ArmaghCounty DownCounty DurhamCounty FermanaghCounty LondonderryCounty TyroneCumbriaDerbyshireDevonDorsetDumfriesshireDunbartonshireDyfedEast LothianEast SussexEssexFifeGloucestershireGwentGwyneddHampshireHerefordshireHertfordshireInverness-shireIsle of ArranIsle of BarraIsle of BenbeculaIsle of ButeIsle of CannaIsle of CollIsle of ColonsayIsle of CumbraeIsle of EiggIsle of GighaIsle of HarrisIsle of IonaIsle of IslayIsle of JuraIsle of LewisIsle of MullIsle of North UistIsle of RhumIsle of ScalpayIsle of SkyeIsle of South UistIsle of TireeIsle of WightKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireLondonMerseysideMid GlamorganMiddlesexMidlothianMorayshireNairnshireNorfolkNorth HumbersideNorth YorkshireNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePerthshirePowysRenfrewshireRoss-shireRoxburghshireSelkirkshireShetlandShropshireSomersetSouth GlamorganSouth HumbersideSouth YorkshireStaffordshireStirlingshireSuffolkSurreySutherlandTyne and WearWarwickshireWest GlamorganWest LothianWest MidlandsWest SussexWest YorkshireWigtownshireWiltshireWorcestershire
5. Postcode *
6. Have you lived in your CURRENT address for more than 5 years? * —Please choose an option—YesNo

7. If you answered YES to the previous question, please skip the next section. If you answered NO please fill in all the relevant fields.

1. Are you a European Union citizen? * —Please choose an option—YesNo
2. Have you applied to the European Union settlement scheme? * —Please choose an option—YesNo
3. Do you need a work permit? * —Please choose an option—YesNo
4. Do you have a biometric residence permit (BRP)? * —Please choose an option—YesNo
5. Do you hold a current driving license? * —Please choose an option—YesNo
6. Do you have a car for work use? * —Please choose an option—YesNo

1. Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013) 2. The amendments to the Exceptions Order 1975 (2013) provide that certain convictions and cautions are protected and are not subject to disclosure to employers and cannot be taken into account.

1. Do you have any convictions to disclose? —Please choose an option—YesNo

   Any information should be given on a separate sheet and sent with this application form. This information will be treated as confidential and will not necessarily preclude you from employment. Please send the separate sheet detailing your convictions to hr@alcg.co.uk.
   Failure to declare or the falsification of any of the above details will result in the withdrawal of any job offer.

1. Statement of your personal qualities and any experiences which are relevant to the post. *

Please give the name and address of one character reference, this could be a reference from a relative or friend.

1. Name *
2. Status *
3. Contact Address *
4. Contact Email *
5. Contact Phone Number *

1. The new General Data Protection Regulation (GDPR) has now come into effect. It's a positive change which will help to give you more control over your personal data and how it's used. Because of these changes, we require your consent so that we can continue to represent you as your employer.
   Please give your consent for Assisted Living Care Group to continue holding your personal information by using and signing this form.
   We take your data rights very seriously and have updated our Privacy Policy to reflect how we use and protect your data. If you have any questions and need more information on the GDPR, please don't hesitate to contact our office and speak to the Management.
   Please acknowledge and confirm your consent for Assisted Living Care Group to process, store and/or transmit any information you provide for the purpose of your employment with Assisted Living Care Group.
   This consent covers all information we may require in order to work with you; including but not limited to processing your application form, references, applying for DBS, identifying clients you will work with and any other purpose that involves your work with Assisted Living Care Group.
   We will not request any information that is not required for a business need while you are employed by Assisted Living Care Group. We take data privacy and security extremely seriously and your information will be processed and secured in accordance with legislative requirements.
   I understand that as part of the contractual arrangements between Assisted Living Care Group Ltd and the Local Authority contracts team, that the monitoring of the contract gives access to my personal file during their monitoring visits. I understand that the Inspection Body has the right to access my file as part of the compliance review process.

1. Do you give your consent for Assisted Living Care Group to hold your details and use them for the purpose of your employment? * Yes, I give my consent.No, I do not give my consent.
2. Name *
3. Date *
4. Telephone *
5. Email *
6. Signature *