DBS Disclosure Application Form

    DBS Disclosure Application Details

    Personal details

    Title
    Forename
    Middle names
    Surname
    NI Number
    Date of birth


    Place of birth

    Town
    County
    Country
    Nationality

    Have you changed your nationality since birth? If 'yes' please state nationality at birth


    Have you changed your birth surname?

    Surname at birth
    Used until
    New surname
    Used until
    New surname
    Used until


    Current Address
    Address line 1
    Address line 2
    Town
    County
    Country
    Postcode
    Dates
    From (Month/year)
    To (Month/year) Present


    Previous Addresses (please continue on separate sheet if more than 3 addresses in 5 years) Please provide all other address' where you have lived in the last 5 years. There must be no gaps.

    Address line 1
    Address line 2
    Town
    County
    Country
    Postcode
    Dates
    From (Month/year)
    To (Month/year)


    Address line 1
    Address line 2
    Town
    County
    Country
    Postcode
    Dates
    From (Month/year)
    To (Month/year)


    Address line 1
    Address line 2
    Town
    County
    Country
    Postcode
    Dates
    From (Month/year)
    To (Month/year)


    Have you ever been convicted of a criminal offence or given a caution, reprimand or final warnings in accordance with the rehabilitation of offenders (exceptions) act 1979? All convictions must be disclosed (not including traffic offences)

    Yes / No

    If ‘yes’ please ensure full details have been recorded on your application form.

    By completing this form, I acknowledge and consent that, M G Care Executive Limited t/a uCheck, may collect and/or receive and/or process certain personal information and data about me. I understand that all of my information (including my personal data) will be collected and processed in accordance with the Data Protection Act 2018, and the General Data Protection Regulations 2016, and UCheck Terms of Use, your Statement of Fair Processing Policy and your Privacy Policy .


    DBS Statement of Fair Processing.
    The Disclosure and Barring Service will refer the details provided on this form to government and law enforcement bodies in accordance with any relevant legislation. The details provided to these bodies will be used for identifying possible matches to records held by them. Where such a match is established, data may be released to the DBS for inclusion on any certificate issued. The details provided on this form may be used to update the records held by the bodies specified above. The details provided on the application form may be used to verify my identity for authentication purposes. The DBS may use any information provided by the DBS on a certificate or otherwise held by the DBS to inform any of its barring decisions made under its powers within the Safeguarding Vulnerable Groups Act 2006. v9.0.

    I agree and consent to the personal information that I provide being processed for the following purposes:

    Disclosure and Barring Service (Enhanced Check).

    • I understand the exact processing of my personal information will depend upon the requirements of my employer. I agree and consent to my personal information being processed by yourselves for any or all of the purposes listed above (if required) by my employer. I understand you will delete any information that I have provided that is not required for processing.
    • I understand that I have provided complete and true information in support of my application and that I understand that knowingly making a false statement for this purpose is a criminal offence.
    • I understand that Starcare have been authorised to access this service by virtue of a contract between you and my employer and that my failure to comply with your Terms of Use , your Statement of Fair Processing Policy and your Privacy Policy will cause my employer to be in breach of contract.
    • I consent to, M G Care Executive Limited t/a uCheck receiving an electronic notification once the application has been processed which states either the 'Certificate contains no information' or 'Please wait to view applicant certificate'.
    • I understand that I may withdraw this consent at any time by giving written notice to M G Care Executive Limited t/a uCheck by emailing M G Care Executive Limited t/a uCheck at the following email address: governance@ucheck.co.uk.

    I have read and understood this statement (check to confirm) Yes

    Starcare will not apply for a DBS until a job has been offered and accepted. By signing this document, you are agreeing/confirming that you understand that, should you then not start/continue your employment with Starcare for at least 6 months after the DBS form has been applied for, you will be invoiced for the amount of £60 (£50 DBS fee + £10 administration). You will then be required to make payment in full within 7 days of the invoice

    Signature of applicant (please draw below with finger or a mouse) [signature* signature-203 cols:300 rows:200 background:#e1e1e1]
    Date
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