Application Form.
Job Advert Reference Number: ….……………………………………………….
Web: www.lodgeclean.co.uk
Please complete this form and email: info@lodgeclean.co.uk
Or;
Lodge Environmental Solutions Ltd
75 Main Road
Drax
Selby
YO8 8NT
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PERSONAL DETAILS:
MR/MRS/MISS/MS:
Surname:
Forename(s):
Address:
Date of Birth:
Name and Address of next of kin:
Postcode:
Postcode:
Home Tel No:
Mobile Tel No:
Tel No:
National Insurance No:
Relationship:
Have you had a CRB disclosure in the last 3
years?
Y/N
Do you have a CCNSG Safety Passport? Y/N
Passport Number:
Do you have a CSCS Card? Y/N
Expiry Date:
Card Number:
Expiry Date:
Have you a current driving licence? YES/NO
If YES give details, e.g. CAR, HGV, PSV, including any endorsements:
Have you ever been convicted of a criminal offence? YES/NO
If YES, give details:
EDUCATION:
Schools/Colleges Attended
Dates From/To
Qualifications attained (including grades)
EMPLOYMENT HISTORY:
(Current or most recent employer first). Please include temporary posts and work experience.
From - To
Name & Address of
Employer
Job Title
Duties
Rate of
Pay
Reason For
Leaving
Notice Required in Current Post:
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REFERENCES.
Please provide the names, addresses and telephone numbers of two persons from whom we
may obtain both character and work experience references. References from your current
employer will not be sought without your authority.
1
2
PERSONAL INTERESTS.
Please note here your leisure interests, sports, hobbies and other pastimes etc. including
offices held in social/sports clubs
LANGUAGE SKILLS.
Which languages other than English do you speak and/or write (tick if fluent)
Language………………………….
Language………………………….
Spoken Y/N
Spoken Y/N
Written Y/N
Written Y/N
ATTENDANCE & RELIABILITY.
Please give details of any absences (other than annual leave), during the last 12 months.
Date:
Reason for Absence:
DECLARATION. ( Please read carefully before confirming)
I confirm that the above information is complete and correct and that any untrue or misleading
information will give the employer the right to reject my application, to withdraw any
employment contract offered or, if employed, dismiss without notice.
Name:
Date:
FOR OFFICE USE ONLY.
Post Applied For:
DATE RECEIVED:
1) Experience
3) Training
5) Circumstances
7) Other
Interview Date:
Times:
2) Qualifications
4) Knowledge/Skills
6) Attendance
Acceptance:
Offer/Rejection Letter:
Medical:
References:
Reasons if Unsuitable:
Additional Comments:
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HEALTH QUESTIONNAIRE. (PRIVATE & CONFIDENTIAL)
Name:
Doctor’s Name and Address:
Please complete this form by answering the following questions. If you answer “yes” please provide brief details:
PAST MEDICAL HISTORY
YES
NO
DETAILS
PAST MEDICAL HISTORY
Allergies/Food/Drugs etc
Bone/Joint
Trouble/Backache
Blackouts/Epilepsy/Fits
Skin Disease
Fainting or Giddiness
Diabetes
Claustrophobia (fear of Confined spaces)
Urinary Complaints
Vertigo (fear of heights)/Dizziness
History of Malignant Brain
Lesion
Heart Trouble
History of Lung Cancer
Raised Blood Pressure
Operations
Indigestion/Dyspepsia
Accident/Injuries
Jaundice
Ear Complaints
Asthma/Bronchitis/Pneumonia
Work with lead/asbestos
Tuberculosis
Previous noise exposure
Disease of Nervous System
Vibration White Finger
Nerves/Anxiety/Depression
Other illness or disability
Are you currently receiving any medical treatment and/or taking any medication:
Do you drink alcohol? If yes, please indicate how many units of wine you drink each week:
YES
NO
DETAILS
(One unit= 1 glass of wine or 1 single measure of spirits. )
Do you smoke? If yes, please indicate the quantity you smoke per day:
Do you have any disabilities which may affect your duties?
If YES, Please give details:
If you have a disability please detail any reasonable adjustments that you believe may be needed either for interview purposes or to enable you to carry
out the post applied for.
I declare that the statements in this form are true and complete. I am aware that any false statement may affect my application. I give consent to a
medical examination if it is necessary. I hereby give my authority for the organisation to contact my doctor for any additional details that may be required.
Signature:
Date:
WHEN THIS FORM IS COMPLETE THE EMPLOYEE MUST HAND
BACK TO THE TEAM LEADER OR HR PERSONELL FOR
INSPECTION. BEFORE COMPELETING ANY OF THE OTHER
DOCUMENTS.
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