01322 271651


Your Name (required)

Your Address (Including postcode)

Your mobile number

Your Email (required)

Your date of birth

National Insurance Number:

Do you have children?

Ages: (required)

Next of kin (Please give name, relationship to you and a contact phone number for them)

Where did you find out about the vacancy

Equal Opportunities recruitment monitoring
As part of our Equal Opportunities policy, we are monitoring job applications to make sure discrimination on the grounds of sex, race and disability do not occur. We would be grateful if you would complete the following.

Are you male or female?

Preferred title

Full Name

Marital status

Ethnic Origin

Do you consider yourself to be disabled under the Disability Discrimination Act? (The Disability Discrimination Act (1995) defines disabilty as "a physical or mental impairment which has a substantial and adverse effect on a person's ability to carry out day to day activities")

Age range

Residency and work permit

Right to work in the UK?

If yes, which is applicable?

Work permit required?

Permit valid until?

I declare that to the best of my knowledge, the information given on this form is correct and complete. I understand that giving false information could lead to my dismissal.

Type your name to sign

Date signed

Confidential pre-employment health questionnaire
The information contained in this health questionnaire will be treated as strictly confidential and will not be divulged to anyone else without your consent.

Please complete this section as accurately as you can, ticking the appropriate boxes and answering questions clearly.

Your doctor's name and address (Including postcode)

Medical history
If you have you ever suffered from any of the following please fill in the box below:
Heart disease/blood pressure/lung disease/jaundice/kidney disease/back pain/psoriasis/ ear disease/eye disease/fits or blackouts/allergies/stomach ulcer/abdominal complaints/diabetes/migraine/urinary disorder/joint pain/ eczema/deafness/poor vision/asthma/serious accident.

Any other long term illness/conditions?

Any operations?

Pacemaker fitted? (company uses powerful magnets)

Are you at present taking any medication?

If yes to the above, please specify:

Are you colour blind?

Do you wear spectacles?

Do you smoke?

If yes, quantity per day;

What is your weekly alcohol consumption (units)?

I declare that the information given in this health questionnaire is true and complete to the best of my knowledge. I understand that giving false information could lead to my dismissal.
I agree to this form being passed to the Company Doctor and am willing to be examined by the Company Doctor.

48 Hour opt out agreement to work longer hours
I understand that the Working Time Directive regulates working time and stipulates that employees should work a maximum 48 hours within a seven day period, averaging over a four month period.
I understand this restriction but I am willing to work longer hours where this is deemed necessary, as allowed in the Work Time Directive. Should I decide to take additional paid employment during my statutory rest periods with Access Staffing Solutions, I accept responsibility should my total hours worked then exceed the maximum set down in the Work Time Directive and will not hold Access Staffing Solutions responsible or liable.
I recognize that this statement in no way amends the health and safety responsibilities (ie Employers Liability Insurance) of the company or myself.


Please check the box below: