NEXT OF KIN AND CONTACT NUMBER *
SKILLS/EXPERIENCE (*circle as appropriate)
Do you have any convictions that are unspent under the rehabilition of offenders act 1974? * if yes please give details * DO YOU HAVE YOUR OWN TRANSPORT? * DO YOU CONSENT TO ADINAS RECRUITMENT TO PASS OVER RELEVANT INFORMATION TO SUPPLIED CLIENTS (TEL NUMBER/DVLA CHECK) WHEN NECESSARY
DO YOU HAVE ANY ENDORSEMENTS? *
If yes please give details
Have you ever been disqualified from driving (if yes please give details)
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.
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
PROOF OF ID
PASSPORT/ID CARD/BIRTH CERTIFICATE ELIGIBILITY TO WORK IN THE UK
SHARED WITH PAYROLL PROVIDER
PASSED TO RELEVANT PAYROLL
LTD COMPANY DOCUMENTS
LTD CO CERTIFICATE
INSURANCE/BUSINESS BANK DETAILS
VAT CERTIFICATE ELIGIBILITY OF SELF EMPLOYED
LTD CO DETAILS NOT INCLUDING
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.
PLEASE LIST AGENCIES IF REGISTERED ELSWHERE Have you had any accidents whilst driving a company vehicle in the last 5 years?
If yes….Please give details REFEREES**TWO MOST RECENT EMPLOYERS 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
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.
DO YOU HAVE ANY PHYSICAL CONDITIONS THAT WILL PREVENT YOU FROM CARRYING OUT THE TYPE OF WORK WE HAVE DISCUSSED HAVE YOU SUFFERED FROM ANY BACK PROBLEMS IN THE LAST 5 YEARS? DO YOU SUFFER FROM ANY SLEEP DISORDERS THAT WOULD PREVENT YOU FROM BEING CONSIDERED TO DO NIGHT WORK? ARE THERE ANY OTHER MEDICAL OR PHYSICAL REASONS THAT YOU ARE AWARE OF THAT WOULD PREVENT YOU FROM WORKING/DRIVING? ARE YOU CURRENTLY TAKING ANY FORM OF PRESCRIPTION MEDICATION?
It is your responsibility to advise Adinas Recruitment when accepting future assignments should your circumstances be any different to the above.
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. 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
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. This field should be left blank