Initial Application Form
Personal Details
Title
Mr
/
Miss
/
Mrs
/
Ms
Forename*
Surname*
D.O.B.*
Telephone
Mobile*
Home Address*
Postcode
Email*
National Insurance No.*
Nationality*
Next of Kin*
Relationship*
Contact Number*
Bank Details
Name of Bank or Building Society*
Branch Address*
Account Name**
Account Number*
Sort Code*
Building Society Roll No (if appl)
Account Holder Signature*
* Required Information ** Ltd Company Workers must have a company bank account
Tax Declaration: Read all the following statements carefully and enter ‘X’ in the one box that applies to you.
Ltd workers need not fill this declaration in.
‘X’
Your Present Circumstances
This is my first job since last 6 April and I have not been receiving taxable Jobseeker’s Allowance
or Taxable Incapacity Benefit or a state or occupational pension.
A
This is now my only job, but since last 6 April I have had another job, or have received taxable
Jobseeker’s Allowance or Incapacity Benefit. I do not receive a state or occupational pension.
B
I have another job or receive a state or occupational pension.
C
Health Declaration
Please answer all of the following declarations honestly, any statements answered yes will require a full medical
questionnaire.
Do you have or have you suffered from any of the following:
Fainting attacks/fits/blackouts
Depression
Recurring headaches
Mental Illness
Chest Conditions
Heart Conditions
Varicose Veins
Muscular or Joint Pain
Recurring Stomach/Bowel trouble
Stress related problems
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
No
No
No
No
No
No
No
No
No
No
Ear trouble or deafness
Asthma
Hay fever
Epilepsy
Eye trouble/defective vision
Abnormal blood pressure
Back Pain
Diabetes
Skin Irritation
Kidney Disease
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
No
No
No
No
No
No
No
No
No
No
Employment History
Are you currently in any other employment?
Yes / No _______________________________
Have you ever been dismissed from employment?
Yes / No _______________________________
Have you ever worked for any other employment agencies?
Yes / No _______________________________
Please enter your employment history below
Name of Employer
Address
Type of
Business
Job Title
From/To
Salary
Please enter 2 referee’s details below:
Name of Referee
Tel. Number
Relationship
Company Address
Reason for
leaving
Qualifications & Skills
Do you have your own transport?
Do you have:
Yes / No
Safety Boots Yes / No
Hi Viz
Yes / No
Please tick which of following class of license you hold:
□B
□ C □ C1 + E □ C + E □ D1 □ D1 + E
Do you hold any of the following qualifications?
Specialist Certificates
Fork lift truck
ADR
Lorry loader
Other
Type
Certificate issued by
Expiry Date
Skills – this section only applies to driving candidates (industrial please see below)
Tick the skills and business areas in which you have experience and would like to work:
Vehicle Type
Operations
Equipment
Gear Box
□ Artics
□ Multi Drop
□ Tail lift
□ Splitter
□ Rigids
□ Trunking
□ Moffett
□ Range Change
□ Tilts
□ Tramping
□ Refrigeration
□ EPS
□ Floating Deck Trailers □ Plan haulage
□ Rope & Sheet
□ Pre-select
□ Draw Bar
□ Shunting
□ HiAb
□ Other
□ A Frame
□ Airports
□ Close coupled
□ Demountables
□ Single/Double deck
□ Tankers
□ Low loaders
□ Containers
□ Bulk
□ Van
□ Any further skills you would like us to know about? _____________________________
Skills – this section only applies to industrial candidates
Tick the skills and business areas in which you have experience and would like to work:
□ Order picking
□ Order packing
□ Mechanical Assembly
□ Re-work
□ Food Production
□ Machine Operating
□ Assembly
□ FLT
□ Goods in/out
□ LLOP
□ MLOP
□ HLOP
□ Labouring
□ PCB Assembly
□ Housekeeping
□ Other_________________________
48 Hour – Working Opt Out
Since August 2009, governmental law states that no employee should have to work more than 48 hours a week over an
average of a 17 week period. If you are 18 or over and wish to work more than 48 hours a week, you can choose to opt out
of the 48-hour limit. If you sign an opt-out, you have the right to cancel this agreement in writing giving at least 2 weeks
notice.
Please sign the below statement if you wish to opt out of the 48 hour Working Time Regulations:
As an employee of The Mercury Recruitment Network, I wish to work more than 48 hours per working week over an average
of 17 week period
Signed: _______________________________________________
Declarations
Have you at any time in the last five years been convicted of any offence?
Yes
/
No
Do you currently have any criminal convictions that are unspent?
If yes please give further details
………………………………………………………………………………
………………………………………………………………………………
Yes
/
No
So that we can continue to ensure that our policies and procedures are effective under section 6 of the Equality Act, 2010
please state if you are registered disabled. Any declaration made will be made at employee discretion however, will only be
used for monitoring purposes and will not be used in assessing and or scoring your application or during the interview
process. The information is kept fully confidential and access is strictly limited in accordance with the Data Protection Act
1998.
Yes
/
No
Personal Declaration
I confirm the information given on my application is correct and there is nothing further, about which I am aware, that should
be taken into account when offering me work. I understand that, should any information prove inaccurate, my assignment
may be terminated.
I hereby authorise The Mercury Recruitment Network Ltd to seek references and I understand the information may be used
to assist with my application for work. I agree that information given on my application may be used for registration purposes
under the Data Protection Act.
Signature
_____________________________________________________________
Print Name _____________________________________________________________
Date
______________________________________________________________
Office Use Only
Interviewed by ________________________________
Date ____________________________
Start Date
Hourly rate _______________________
_______________________________
Suitability to work________________________________
Attitude to work ___________________
Ideal Sites of work________________________________ Holidays Booked___________________
Worker Aged over 23 years?_______________________
Comments: