Application Form

Personal Details
Select:
Name:
Address:
Phone:
-
E-mail:
Date of Birth:
National Insurance Number:
Licence/Driving Details
Own Transport:
Other Transport:
Domestic Licence Number:*
Expiry Date:*
LGV Expiry Date:*
Please tick items of which you have a good knowledge and experience of
Driving Experience: Tick those that apply
Good knowledge of local areas, please list the areas you are familiar with:
Career History

First Reference

Previous Employer 1:*
Previous Employer 1 Address:*
Previous Employer 1 Contact Name:*
Previous Employer 1 Job Title:*
Previous Employer 1 Phone:*
Employment from:*
Employment to:
Reason for leaving:*
Second Reference
Previous Employer 2:
Previous Employer 2 Address:
Previous Employer 2 Contact Name:
Previous Employer 2 Job Title:
Previous Employer 2 Phone:
Employment 2 from:
Employment 2 to:
Reason for leaving 2:

Declarations

I confirm that to the best of my knowledge the information supplied by me is correct, and that I am not aware of any adverse information which I have not disclosed which may effect my employment. I accept that I must keep GKH Recruitment Ltd informed at all times of any changes to my personal and licence details.

1. Have you at any time in the last five years been convicted of any motoring offences?:*
1. If yes please give details below:
2. Have you during the past ten years had your licence suspended?:*
2. If yes please give details below:
3. At the time of signing this form are there any pending prosecutions either vehicle or criminal which may effect your employment with GKH:*
3. If yes please give details below:
4. Do you have a criminal record?*
4. If yes please give details below:

STRICTLY CONFIDENTIAL

Employee Medical History Details

The details below should be completed as fully as possible.

Doctors Name:*
Doctors Phone:*
-
Doctors Address:*

IMPORTANT: The information supplied is to the best of my knowledge correct and I understand that failure to disclose the relevant information or giving false information may result in my termination of employment.

Have you ever suffered from any of the following illnesses?

1. Do you have any eyesight defects other than those corrected by glasses or contact lenses? *
2. Do you have any hearing defects? *
3. Do you have any defect of speech or communication problem?*
4. Do you have any physical disabilities that will necessitate in special aids,or requirements for access to premises?*
5. Are you currently attending a doctor?*
6. Have you ever suffered from black outs, fainting, epilepsy or fits?*
7. Have you ever suffered recurrent headaches or migraines? *
8. Have you ever suffered from heart disease or high blood pressure?*
9. Have you ever suffered from diabetes, thyroid or any other gland problem?*
10. Have you ever suffered from any drug or alcohol related problems? *
11. Any other medical condition, physical or mental, not mentioned above?*

Next of Kin

Contact 1 Name:*
Contact 1 Address:*
Contact 1 Phone:*
-



Contact 2 Name:
Contact 2 Address:
Contact 2 Phone:
-



Contact 3 Name:
Contact 3 Address:
Contact 3 Phone:
-

Bank Details

Bank Name:*
Account Name:*
Branch:*
Sort Code:*
Account Number:*

Declaration:

I confirm the details shown are correct and I accept full responsibility for any errors.

Declaration Signature:*
Date Signed:*
Anti Spam Verification:

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