If you lived less then five years in the above address, please provide your previous address(es)
(Please provide details of your employment history for the last 5 years, including details of full time
education if it falls within that period. Include periods of self-employment and military service. For any periods of unemployment give the address of the DWP Office to which you reported.)
Can we contact your present employer?
Do you have any special requirements if invited for an interview.
Are there any medical reasons why you should not do shift work?
Are you able to carry out strenuous physical work including climbing Ladders, working from scaffolding, bending, lifting and carrying?
Have you ever had to give up any previous job for medical reasons?
Have you ever had any treatment requiring hospital admission for five or more days?
Is your eyesight normal (with glasses if worn)?
Is your hearing normal?
Any other heart trouble?
Raised blood pressure?
Indigestion for more than one week?
Back trouble, lumbago, sciatica, “slipped disc”?
Peptic, gastric or duodenal ulcer?
Bronchitis, asthma, pneumonia?
Dermatitis, eczema or any other skin troubles?
Migraine or sever recurring headaches?
Fainting attacks or giddiness?
Anxiety, depression or any other nervous complaint?
Kidney trouble or urinary infection?
I am willing to undergo a medical examination if required and I declare that the information I have given on this form is correct to the best of my knowledge.
I agree that the Company may consult my own Doctor in relation to any information I have given on this questionnaire.
Have you Ever been Fined, Imprisoned, Placed on Probation, Discharged on Payment of Costs or Had any Order Made against you by a Criminal, Civil or Military Court or Public Authority
Have you any alleged offences outstanding against you?
Do you have any special requirements if invited for an interview
I certify that to the best of my knowledge the information I have given is true and complete. I understand that any false statement or omission will render me liable to dismissal any may result in prosecution. Any information will be treated in confidence.