Please enable JavaScript in your browser to complete this form. - Step 1 of 6Personal detailsPlease re-enter your name and Email addressName *FirstLastE-mail Address *NextNational Insurance Number *Date of birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you need a permit to work in the UK? *YesNoPlease provide your work permit / visa number *Are there any restrictions on your visa? *YesNoPlease detail these restrictions *Do you have a full driving license *YesNoIs it clean? *YesNoDo you have daily use of a car? *YesNoIf no please give details *How long are you prepared to spend travelling to work? *Do you have any unspent criminal convictions *YesNoIf yes please give details *Next of kin name *FirstLastNext of kin phone number *What kind of work are you looking for? *PermanentTemporary or ContractSelect one or moreWhen are you available to start work? *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NextEducation and qualificationsPlease include both educational and vocational qualifications starting with the most recent and going backwards in time. *Pleas use the format of: Date (from - to), Educational Institution, Qualifications ObtainedEmployment history *Please detail your full employment history starting with your most recent employer (stating if it was a recruitment agency) and continuing backwards in time. Please ensure that dates provided include both month and year.NextMedical questionnaireHave you been absent from work in the last two years due to illness *YesNoNumber of daysHave you ever left or retired from a job for medical reasons? *YesNoIf yes please elaborateHave you ever had any illness that may have been caused by or made worse by work? *YesNoIf yes please elaborateDo you consider yourself to have a disability? *YesNo If yes and you feel that you need any adjustments or modifications to do the job for which you are applying, please give details:Have you seen any doctor in the last two years for any kind of health problem? *YesNoAre you having any treatment or investigations of any kind now? *YesNoAre you waiting for any treatment or investigations? *YesNoDo you have any eyesight problems not corrected by glasses? *YesNoDo you have any hearing problems not corrected with a hearing aid? *YesNoDo you have any difficulty in standing, bending, lifting or any other movements? *YesNoHave you ever had any back, shoulder, arm, wrist, or neck pain lasting more than 3 days? *YesNoHave you ever had any problem with your joints, including pain, swelling or stiffness? *YesNoIf yes please elaborateHave you ever had any mental illness or psychological problems including depression, anxiety, schizophrenia, or self-harm? *YesNoIf yes please elaborateDo you have any digestive problems? *YesNoHave you ever had any drug or alcohol related problems? *YesNoHave you ever had seizures, epilepsy, blackouts, sudden unexplained dizziness, or loss of consciousness? *YesNoAre there any other conditions you should mention? *NextReferencesPlease provide details of two previous employers from whom we can obtain references. Any offer of employment is conditional on our receiving two satisfactory references. We will not approach your present employer until an offer of employment has been made and verbally accepted. Providing two references will assist with the application processMost recent employer contact name *FirstLastMost recent employer job title *Most recent employer company name *Most recent employer address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeMost recent employer telephone *Most recent employer email address *Other employer contact name *FirstLastOther employer job title *Other employer company name *Other employer address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeOther employer telephone *Other employer email address *NextAgreement48 Hour Opt Out Note: You are under no obligation to agree to the provisions set out in this Schedule. If you indicate in the signature box of the agreement that you agree to opt out in accordance with this Schedule, this Schedule will then apply. Otherwise the limit set in the WTR shall apply. Agreement: The nature of an Assignment may require you to choose whether to work in excess of the maximum working time specified in Regulation 4(1) WTR, namely an average of 48 hours each Week calculated over a 17 Week reference period. You wish to have the opportunity to provide the Services during any excess period required from time to time, whether or not you choose to work for that time. Pursuant to Regulation 5 WTR you accordingly agree that the limit specified in Regulation 4(1) WTR shall not apply to any Assignment or the work you perform, and this agreement shall have effect immediately. The agreement set out in the above clause 3 of this Schedule applies to each Assignment but you may, by giving written notice to us of not less than one month, terminate your agreement to disapply the limit on weekly working time without otherwise affecting the operation of the terms of your employment. By signing this agreement, you confirm that you are over 18 years of age. Signature *Clear SignatureDECLARATION By signing below, you are: Confirming that the information you have given is correct and that you have not withheld any information of which the company should be made aware. You also understand that giving any incorrect or misleading information could lead to your subsequent dismissal, withdrawal of a job offer or termination of an assignment. Giving your explicit consent for Ardent Personnel Ltd to collect, process and share your personal data and sensitive personal data with relevant internal and external third parties in order to process your application, complete pre-employment/pre- engagement vetting and checks and obtain references to support your job search. Detailed information about how your data will be used, together with your rights under the General Data Protection Regulations (GDPR) can be found in our Privacy Policy which is available at www.ardent-personnel.co.ukSignature (copy) *Clear SignatureSubmit