Application Form

SURNAME*

FORENAMES*

ADDRESS(inc postcode) *

MOBILE*

NATIONAL INSURANCE NO.*

EMAIL ADDRESS *

DATE OF BIRTH*

NEXT OF KIN AND CONTACT NUMBER*

LICENCE HELD*

VAN

7.5T

SKILLS/EXPERIENCE (*circle as appropriate)

FRIDGE/CHILLED*

Yes

SKIPS*

Yes

Do you have any convictions that are unspent under the rehabilition of offenders act 1974?*

Yes

if yes please give details*

DO YOU HAVE YOUR OWN TRANSPORT?*

Yes

DO YOU CONSENT TO ADINAS RECRUITMENT TO PASS OVER RELEVANT INFORMATION TO SUPPLIED CLIENTS (TEL NUMBER/DVLA CHECK) WHEN NECESSARY

Yes

DO YOU HAVE ANY ENDORSEMENTS?*

Yes

If yes please give details

CODE

Date

Have you ever been disqualified from driving (if yes please give details)

DVLA CHECK

By signing below you are confirming the driving licence of the above indidviual is valid and with the number of points stated. The drivers confirms they have no pending prosecution and to notify Adinas of any changes or endorsements they may incur from the date of the dvla check. The driver also gives permission for Adinas to check at 3 monthly intervals on DVLA.

Signed

Date

Points

DOCUMENTS	REASON	MITIGATION (information shared with)
RIGHT TO WORK DOCUMENTS NATIONAL INSURANCE/DRIVING LICENCE AND/OR OTHER CARDS/PROOF OF ADDRESS	ELIGIBILITY TO WORK IN THE UK PROOF OF VALIDITY TO DRIVE	DRIVING LICENCE SHARED WITH PAYROLL PROVIDER
PROOF OF ID PASSPORT/ID CARD/BIRTH CERTIFICATE	ELIGIBILITY TO WORK IN THE UK	SHARED WITH PAYROLL PROVIDER
BANK DETAILS	PAYROLL	PASSED TO RELEVANT PAYROLL PROVIDER
LTD COMPANY DOCUMENTS LTD CO CERTIFICATE INSURANCE/BUSINESS BANK DETAILS VAT CERTIFICATE	ELIGIBILITY OF SELF EMPLOYED	LTD CO DETAILS NOT INCLUDING BANK DETAILS HMRC INTEMEDIARY REPORT

Personal information in the form of Name/Telephone number will be passed to clients to whom you are supplied to for work along with your current DVLA check. Please sign to authorise Adinas Recruitmentto store the above documents in a secured location.

Signed

Date

Employee Signature

Date

PREVIOUS WORK HISTORY

EMPLOYER-1

EMPLOYER*

CONTACT*

NUMBER*

ADDRESS*

START DATE*

END DATE*

POSITION *

REASON FOR LEAVING*

EMPLOYER-2

EMPLOYER*

CONTACT*

NUMBER*

ADDRESS*

START DATE*

END DATE*

POSITION *

REASON FOR LEAVING*

EMPLOYER-3

EMPLOYER

CONTACT

NUMBER

ADDRESS

START DATE

END DATE

POSITION

REASON FOR LEAVING

OTHER AGENCIES

PLEASE LIST AGENCIES IF REGISTERED ELSWHERE

NAME

FROM- TO

Have you had any accidents whilst driving a company vehicle in the last 5 years?

Yes

If yes….Please give details

REFEREES**TWO MOST RECENT EMPLOYERS

NAME*

JOB TITLE*

WORK RELATIONSHIP *

COMPANY*

DATES EMPLOYED FROM TO *

ADDRESS

TEL NO

NAME*

JOB TITLE*

WORK RELATIONSHIP *

COMPANY*

DATES EMPLOYED FROM TO *

ADDRESS

TEL NO

Bank Details

Account Holder*

Account Number*

Sort Code*

Bank Address*

DRIVER DECLARATION ROAD TRANSPORT(WT)REGULATIONS

It is your responsibility to inform Adinas Recruitment of all your working Time during the reference periods we use and to keep us updated as to any additional Working Time you undertake for other employers or employment businesses for these purposes during an assignment. It is also your responsibility to accurately record your Working Time during an assignment. Both Transport and non Transport work must be taken into account. Accordingly please provide details of Working Time undertaken for any other employers or employment businesses during the current 6 week reference period. See below the dates of the relevant 6 week reference period. If you are engaged in charitable or voluntary work, or work for the TA, fire service or police you must inform us and you should fill out the chart below as if you were engaged in other work, even though we may

I am not currently engaged in any work outside my commitments to RDS(Mansfield)ltd t/a adinas which would need to be included in calculations of my working time under The Road Transport (Working Time)Regulations 2005. I undertake to inform ADINA'S immediatley if this situation should change and to provide details as set out below and in weekly time sheets. exclude.

I am currently engaged in any work outside of my commitments to RDS(Mansfield)ltd t/a adinas which will need to be included in calculations of my working time under The Road Transport (Working Time)Regulations 2005. I undertake to keep ADINA'S informed if there is any change to these details and to record details of hours worked for all employers in my weekly timesheets.

For the purpose of calculating the 48 hour avenage the reference period shall be successive 26 week periods. The first day of a 26 week reference period will begin at 00.00 hours on Monday. The reference periods that will apply to to mobile workers will be 07.01.2019 to 14.07.2019 and 15.07.2019 to 05.01.2020. This pattern of fixed calendar reference periods will continue until this agreement is terminated.

EMPLOYER-1

Name of Employer

Type of Work

Week Commencing

Hours Worked

EMPLOYER-2

Name of Employer

Type of Work

Week Commencing

Hours Worked

MEDICAL QUESTIONNAIRE

DO YOU HAVE ANY PHYSICAL CONDITIONS THAT WILL PREVENT YOU FROM CARRYING OUT THE TYPE OF WORK WE HAVE DISCUSSED

Yes

HAVE YOU SUFFERED FROM ANY BACK PROBLEMS IN THE LAST 5 YEARS?

Yes

DO YOU SUFFER FROM ANY SLEEP DISORDERS THAT WOULD PREVENT YOU FROM BEING CONSIDERED TO DO NIGHT WORK?

Yes

ARE THERE ANY OTHER MEDICAL OR PHYSICAL REASONS THAT YOU ARE AWARE OF THAT WOULD PREVENT YOU FROM WORKING/DRIVING?

Yes

ARE YOU CURRENTLY TAKING ANY FORM OF PRESCRIPTION MEDICATION?

Yes

It is your responsibility to advise Adinas Recruitment when accepting future assignments should your circumstances be any different to the above.

Declarations

Drivers Fine - I understand that whilst on any assignment for Adinas Recruitment, I am liable for all fines including Administration charges this may incur relating to all traffic and all parking offences and authorise Adinas Recruitment to supply any relevant personal information regarding myself to the client and all relevant parties in relation to traffic and parking offences. The client is allowed to pass on costs of valeting should they find that you have been smoking in the vehicle.I authorise all such fines to be deducted from my next payment of wages upon notification from Adinas Recruitment.

SIGN

Date

Acknowlegement Declaration

I confirm that I have read and understood the attached forms and that to the best of my knowledge all information given is true and complete. I understand that any false statement, misrepresentation, or omissions of information made on this form may disqualify me from employment. I consent to the company recording my data contained on this form and contact my present and/or previous employers for a reference.
I confirm I have a legal right to work in the UK and have produced legal and appropriate documents as evidence to confirm this prior to working at Adinas Recruitment.

Signed

Interview conducted by

Date

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