Position Applied For (please include the ref number)*
Date Of Application*
Surname*
Forename(s)*
Maiden Name (If Applicable)
Day Telephone Number*
Mobile Number
National Insurance Number*
Email Address*
Nationality*
Address*
How long have you lived at this address? (Years)*
Date of Birth*
Age*
Place of Birth*
English Proficiency* —Please choose an option—PoorBasicGoodExcellent
Full Name*
Relationship*
Phone Number*
Current Drivers Licence* —Please choose an option—YesNo
Access to Car? —Please choose an option—YesNo
To gain employment within the United Kingdom & NI you must supply your employer with a share code.
Residency Share Code
Please Upload a Photo of the ID you used when applying for status.
Full Time* —Please choose an option—YesNo
Part Time* —Please choose an option—YesNo
Evenings* —Please choose an option—YesNo
Nights* —Please choose an option—YesNo
Weekday Availability MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Length of Absence
Cause
Please complete the following questions by selecting the appropriate answer. If the answer is yes to any question, please give details of (1) Date; (2) Amount of time lost from work ;(3) any treatment at present or planned for the future. Complete the questionnaire as fully as possible and continue on a separate sheet if necessary. The information will be treated in confidence. If information is withheld, suppressed, or is deliberately misleading or false, you may be liable for dismissal.
Have you ever had a history of diarrhoea or tummy trouble lasting 24 hours or more? —Please choose an option—YesNo
Have you a history of ulcers or indigestion? —Please choose an option—YesNo
Have you been outside the UK or Ireland during the past 12 months? —Please choose an option—YesNo
If YES, which country/countries have you visited?
Have you ever had fainting attacks or giddiness? —Please choose an option—YesNo
Have you ever had blackouts, epilepsy or fits? —Please choose an option—YesNo
Have you ever had a history of skin disease, e.g. rashes, dermatitis or eczema? —Please choose an option—YesNo
Have you ever had any discharge from your eyes, ears or nose? —Please choose an option—YesNo
Have you ever had any trouble, with teeth or gums? —Please choose an option—YesNo
Have you ever had any history of joint trouble, e.g. sore hands, wrists, elbows or arms? —Please choose an option—YesNo
Have you had a history of back trouble, e.g. Strain, sciatica or disc problems? —Please choose an option—YesNo
Have you a history of bronchitis, asthma, or TB? —Please choose an option—YesNo
Do you smoke? —Please choose an option—YesNo
Have you ever had a urine infection, bladder infection or kidney problems? —Please choose an option—YesNo
Have you ever had problems with your blood pressure? —Please choose an option—YesNo
Have you ever had an injury or disease not already mentioned? —Please choose an option—YesNo
If YES, please explain.
Have you ever had any hospital investigations or treatment? —Please choose an option—YesNo
Have you a hearing problem or condition of any kind? —Please choose an option—YesNo
Do you wear glasses? —Please choose an option—YesNo
Are you at present on any treatment such as injections, tablets or medicines? —Please choose an option—YesNo
Do you suffer from any allergies? —Please choose an option—YesNo
Have you ever had a previous industrial accident or suffered previous industrial injury? —Please choose an option—YesNo
Have you had any of the following immunisations? TetanusPolioB.C.G (for TB)Rubella (German Measles)MMR (Measles, Mumps, Rubella)Hepatitis BHepatitis ATyphoid
I Accept
