PERSONAL DETAILS Forename: Surname: Previous Names(if applicable): Date of Birth: Home Address: Postcode: Daytime Contact Number: Evening Contact Number: Email Address: National Insurance Number: NEXT OF KIN Name: Relationship: Mobile Number: Landline: EMPLOYMENT HISTORY Please begin with the most recent, giving details of any gaps in employment and the reason for these. Full history is required. Name of most recent Employer: Address, Email & contact number of Employer: Job Title and Brief Outline of Duties: Dates From - To (Month & Year): Reason for Leaving: Salary / Rate of Pay: Name of Employer: Address, Email & contact number of Employer: Job Title and Brief Outline of Duties: Dates From - To (Month & Year): Reason for Leaving: Salary / Rate of Pay: Name of Employer: Address, Email & contact number of Employer: Job Title and Brief Outline of Duties: Dates From - To (Month & Year): Reason for Leaving: Salary / Rate of Pay: Name of Employer: Address, Email & contact number of Employer: Job Title and Brief Outline of Duties: Dates From - To (Month & Year): Reason for Leaving: Salary / Rate of Pay: EDUCATION, QUALIFICATION AND TRAINING Please list in Chronologial Order School: School Qualifications: Leaving Date: College: College Qualifications: Course Completion Date: University: University Qualification: Course Completion Date: Other Qualifications/Training: Place of Study: Course/Training Completion Date: REFERENCES Please include below the name, status, address and telephone number of referees Previous Employer and / or Name of Line Manager: Name and Position: Address: Telephone Number: Mobile Number: YOUR SKILLS Please check the buttons below to indicate skills in any of the following: PackingPickingGoods InGoods OutProduction OperativeAssemblyParcel SorterCNC MillingCNC LatheArc WeldingLabouringPunch PressPower PalletForklift BendiForklift Customer BalanceForklift Man DownMachine SetterPalletisingTig WeldingQuality InspectionPower PressElectrical MaintenanceVoice PickerOfficeAccountsSales VACANCY PREFERENCES Please answer Yes or No Preferred Hours: Full TimePart Time Preferred Shifts: Days/LatesShifts Duration: TemporaryPermanent Weekends: YesNo PAYMENT DETAILS Payment of hours worked will be made weekly in arrears directly in the bank account details below. Please ensure the details are correct. Bank Name: Name of Account holder: Bank Address and Postcode: Account number: Sort Code: PAY SLIPS Please indicate to agree that your payslip will be sent electronically as an e-payslip to the email you provide below. If a printed copy is required there will be an admin charge. Please send my payslips electroncially: YesNo Email to send payslips to: Would you be interested in receiving more information on our workplace pension? YesNo AGREEMENTS Do any of your beliefs restrict you from working in any particular environments?: YesNo If you answered Yes, please give details: Would you be prepared to take a drug or alcohol test? (This is a requirement for some our clients) YesNo Are you happy to allow us to provide your data to clients for the purpose of work finding activity? YesNo STAY CONNECTED The law has changed and to ensure you still receive information from us about job vacancies you will need to opt into the below methods of communication. There will be some circumstancs where we will be able to contact you without an opt in, but these will be limited. I would like to receive alerts from JS Talent Specialists Ltd about current and upcoming vacancies via the following methods (please tick): TelephoneSMSEmail CRIMINAL CONVICTIONS Do you have any current or pending criminal convictions or prosecutions, other than those spent under the Rehabilitation of Offenders Act? Please indicate Yes or No: YesNo If Yes, Please give details: Have you ever served a custodial sentence: YesNo MEDICAL FITNESS It is your right under the Working Time Regulations 1998 to have a health assessment whilst you are a night worker and at regular intervals thereafter. This questionnaire will be used to assess if you have any condition which may affect your ability to do night work only. Any medical details you give are confidential. Doctors Name: Doctors Number: Doctors Address and Postcode: YOUR HEALTH Do you have, or have you suffered from any of the following. Please select yes or no and if yes provide details in the space provided at the bottom of this section. Headaches or migraines: YesNo Stomach Ulcer: YesNo Mental Illness: YesNo Fits/Epilepsy/Blackouts: YesNo Back Trouble: YesNo Anxiety or Depression: YesNo Fainting or dizzy spells: YesNo Joints complaints or arthritis: YesNo Chest disease: YesNo Swollen ankles: YesNo Breathing problems: YesNo Varicose veins: YesNo Asthma: YesNo Abnormal blood pressure: YesNo Heart trouble or surgery: YesNo Skin complaints / dermatitis: YesNo Abdominal problems: YesNo Impaired vision / eye trouble: YesNo Bladder, liver or kidney trouble: YesNo A requirement to wear glasses: YesNo Diabetes: YesNo Hearing or ear problems: YesNo Hernia or rupture: YesNo A requirement to wear a hearing aid: YesNo Have you ever had any problems affecting your ability to complete any of the following. If yes, again, please provide details beneath. Stand or walk: YesNo Use your hands: YesNo Lift: YesNo Climb stairs / work at height: YesNo Wear Safety Footwear: YesNo Drive a motor Vehicle: YesNo Additional details on any of the above (optional) ADDITIONAL INFORMATION Do you have, or have you suffered from any of the following. Please select yes or no and if yes provide details in the space provided at the bottom of this section. Have you ever been or are you currently registered disabled?: YesNo Do you take any regular medication?: YesNo Do you have any allergies?: YesNo Have you ever been dismissed or refused employment for health reasons?: YesNo Have you ever been absent from work for over 3 months due to sickness or injury?: YesNo Have you ever been absent from work for more than 10 days due to a medial reason?: YesNo Have you ever received compensation for an injury or illness sustained at work?: YesNo Do you have any blood relations that suffer from any hereditary disease including heart disease and asthama?: YesNo Does any of your close family suffer from serious health problems?: YesNo Do you have any medical condition affecting your ability to sleep?: YesNo Do you have any other health conditions / health problems that may affect your ability to do night work?: YesNo Please state your weekly alcohol intake (units): Please state your weekly Tobacco / Cigarette Intake: Please Note: The information provided in this questionnaire is strictly confidential; however, we need your consent to allow us to disclose this information to clients of Step JS Talent Recruitment Specialists Ltd upon request. As a result of the information that you have provided you may be referred to your doctor for a medical fitness certificate before JS Talent Recruitment Specialists Ltd can offer you certain work placements. Failure to disclose any information regarding your fitness, or making false declarations, may result in JS Talent Recruitment Specialists Ltd having to terminate your contract. I hereby certify that I have answered all the above questions truthfully and to the best of my knowledge. I know of no reason that I am medically unfit for work. I hereby give my consent to the information provided being disclosed to clients of JS Recruitment Specialists Ltd where requested. YesNo Date: EQUALITY AND DIVERSITY As an equal opportunity employer. The aim of the policy is to ensure no job applicant, employee or worker is discriminated against either directly or indirectly on the grounds of rafe, colour, ethnic or national origin, religious belief, political opinion or affiliation, sex, marital status, sexual orientation, gender re-assignment, age or disability. Our recruitment criteria and procedures are frequently reviewed to ensure that individuals are selected, promoted and treated on the bases of their relevant merits and abilities. All employees are given equal opportunity and encouraged to progress within the organisation. We are committed to an on-going programme of action to make this policy fully effective. You ensure that this policy is fully and fairly implemented and monitored, and for no other reason. Please provide the following information which will be detached from the rest of your application and retained by the H.R. Department before shortlisting. Are you: MaleFemaleOtherQuestion Declined ETHNICITY: Are you: White BritishWhite IrishWhite & Black CaribbeanWhite & Black AfricanWhite & AsianWhite OtherMixed OtherAsian / Asian British: IndianAsian / Asian British: PakistaniAsian/Asian Black – BangladeshAsian / Asian British: OtherBlack/Black British: CaribbeanBlack/Black British: AfricanBlack / Black British: otherChineseOther Ethnic GroupNot KnownNot disclosed DISABILITY: Under the Equality Act 2010 (Disability) Regulations 2010 a person considered to have a disability if he/she has a physical or mental impairment which has sustained a long-term adverse effect on his/her ability to carry out normal day-to-day activities. Do you consider yourself a disabled person?: YesNoQuestion Declined SEXUAL ORIENTATION: How would you describe your sexual orientation? HetrosexualHomosexualBisexualTrans RELIGIOUS BELIEFS: What is your religious belief? BuddistMuslimChristianSikhJewishNo ReligionDeclinedOther Belief (Please specify below) Other belief (If selected above) MARITAL STATUS: How would you describe your status? Married/Civil PartnershipSingleWidowedDivorced Data Protectin Act 1998. This form will be kept confidentially by JS Recruitment Specialists and used for th exclusive purpose of recruitment and employment. Once the recruitment and selection process are complete, the data will be stored and used for your personal records. Please indicate your consent for the information to be used for this purpose: YesNo Name: Date Of Birth: Todays Date: WORKING TIME DIRECTIVE This agreement is made between JS Talen Recruitment Specialists and the Worker. Agreement: The Working Time Regulations 1998 provide that the average working week, including overtime, shall not exceed 48 hours. By signing this agreement, the Company and the Worker agree that the time limit to working hours shall not apply to the Worker. This agreement will remain in force indefinitely or until such time as the Company or the Worker terminate the agreement. Written notification much be given to terminate this agreement. Please indicate your agreement: YesNo Name: Date Of Birth: Todays Date: TERMS OF ASSIGNMENT Please read the Terms of Assignment (opens in new window) I confirm that I have read, understood and agree these standard Terms of Assignment above and agreed to my name being included on the JS Talent register of people who may be contacted for assisgments, and that my details may be forwarded to Clients.: YesNo Name: Todays Date: FINAL DECLARATION AND AGREEMENT I hereby certify that the information that I have provided in this document is true and to the best of my knowledge. I authorise JS Talent Recruitment Specialists Ltd to use any or all of this information in conjunction with my application for work placements. I consent to provide electronic signature for the information provided in this form. Signature (Type your full name): Todays Date:
