Giffords Way
Off Kelvin Way
West Bromwich
West Midlands B70 7JR

Tel +44 (0)121 553 1910
Fax +44 (0)121 500 4919
Email info@giffords.biz
www.giffords.biz

Job Application Form

Part 1: Your Details

Surname: * Other Names: *
Position applied for: *
Private Address: *
Postcode: *
Telephone (home): * Mobile:
Email Address: *
National Insurance No.:
Do you need a work permit to work in the UK? * YES NO

Part 2 : Driving License Details
Do you have a current driving license? * YES NO    (If NO. please move on to Part 3)  
License Type: (e.g. Car, HGV)
If you have an FLT license please state which type:
Do you have any endorsments? YES NO
If YES, please give details:

Part 3 : How You Heard About This Vacancy

What prompted your application to Giffords Recycling Limited?
Agency Advertisement
Relative or Friend Walk in
Other Employee referral
If OTHER, please give details:

Part 4 : Criminal Record

If you have been convicted of any offence or if there are any proceedings pending against you, please give details and dates. If none, please write "none". *
(Under the Rehabilitation of Offenders Act 1974 only relevant convictions will be taken into account when assessing your capability).

Part 5 : Education

Please list any relevant educational, and other, qualifications held (including level and date obtained) or training received. Please also list any membership of professional / technical organisations.
Institution: *
(school/college etc) 		Entered: Left: Qualifications: *
+ click here to add details of more Schools, Colleges etc.

If you have any other professional qualifications, or have attended training or short courses that you think are relevant to this application please give details below:

Part 6 : Employment History

Please list below your complete employment history, from most recent employment to your least recent employment. Please include any periods of unemployment. We reserve the right to contact any of your previous employers to obtain a reference.

This section must be completed.

Your current employment details
Current Position: *
(If unemployed please write "unemployed")
Current employer: Your Salary:
Address of employer: Brief description of duties:
Start Date:
Notice required:
Reason for leaving:
Previous employment details
Position Held:
Company Name: Your Salary:
Company Address: Brief description of duties:
Start Date: Leaving Date:
Reason for leaving:
+ click here if you wish to add more previous employers.

Part 7 : Your References

Please provide the details of one current/previous employer that we may contact for a reference.
If you have no employment history, please provide the details of one college/training/school official.

Name: * Address:
Position: *  
Company: *  
Telephone Number: * Postcode:

May we contact this person at this stage without further reference to yourself? * YES NO
Do you have a relative or friend working at Giffords Recycling Limited? YES NO
If yes, who?
If your application is successful, will this be your only job? YES NO

Part 8 : Medical History

Giffords Recycling Limited is concerned about the health and safety of its employees and every effort will be taken to minimise potential health risks to yourself and other workers. The information you provide in this section will remain confidential. Failure to disclose or the giving of false information could put yourself or others at risk and may lead to termination of any employment offered to you.

Please answer the questions below:

Do you have any disabilities which may affect your work? YES NO
If yes, please give details:
Are you attending or waiting to attend hospital for treatment or surgery? YES NO
If yes, please give details:
Are you at present under medical supervision or taking any tablets, inhalers, medicine or injections? YES NO
If yes, please give details:
Do you have any problems with vision, hearing, reading or writing? YES NO
If yes, please give details:
Have you ever experienced work problems related to your previous work duties? YES NO
If yes, please give details:
How many periods of sickness have you had in the past year?
Have you attended hospital, doctor or clinic in the last 12 months for neck, back, hand, wrist, knee or foot problems? YES NO
If yes, please give details:

Have you suffered from any of the following?
Back trouble (backache, back injury or slipped disc)? YES NO
Details (including dates)
Difficulty in bending/lifting or sitting for long periods? YES NO
If yes, please give details:
Muscular or joint problems which may affect your work? YES NO
If yes, please give details:
Asthma, bronchitis, pneumonia, pleurisy or other chest illness? YES NO
If yes, please give details:
A cough for more than 3 weeks in the past 12 months? YES NO
If yes, please give details:
Coughed up blood/unexplained night sweats/loss of weight/fever in the past year? YES NO
If yes, please give details:
Have you or a close member of your family suffered from T.B.? YES NO
If yes, who?
Have you had a chest X-Ray within the last 24 months? YES NO
If YES, please give details below:  
Date of the X-Ray: Place:
Reason:
What action was taken, if abnormal?
Recurrent or prolonged infections/diarroea? YES NO
If yes, please give details:
Diabetes, thyroid or other gland disorders? YES NO
If yes, please give details:
Dermatitis/Eczema/Psoriasis or other skin complaint and area(s) affected? YES NO
If yes, please give details:
Nervous, depressive or psychiatric problems? YES NO
If yes, please give details:
Epilepsy or blackouts? YES NO
If yes, please give details:
Raised blood pressure or heart problems? YES NO
If yes, please give details:
Do you have any allergies? YES NO
If yes, please give details:
Other illnesses/infection/operation or injury not mentioned above (other than childhood illnesses) YES NO
If yes, please give details:

Part 9 : Equal Oppurtunities

Giffords Recycling Ltd is committed to ensuring equality of opportunity. Your application will be considered on your ability ONLY. Information requested below will ONLY be used to monitor the Company's practices and will be treated confidentially.

If you fail to complete this section fully, it will be viewed as indicating your implied opposition to the Equality Policy and your application will not be accepted.
Which age group do you belong to? *
16 - 21 22 - 30
31 - 39 40 - 49
50 - 59 60 - 65
What is your Nationality? *
What is you gender? * MALE FEMALE

Please tick the appropiate box which describes your ethnicity: *

White: British
  Irish
  White Other (please state):
Mixed Race: White & Black Caribbean
  White & Black African
  White & Asian
  Mixed Race Other (please state):
Asian or Asian British: Indian
  Sikh
  Pakistani
  Bangladeshi
  Any other Asian background (please state):
Black or Black British: Caribbean
  African
  Any other Black background (please state):
Other ethnic groups: Chinese
  Yemeni
  Any other ethnic group (please state):
Do you have, or have you had in the past, any disability which makes it difficult for you to carry out normal day to day activities? * YES NO
If yes, please give details:

Please identify any special requirements or equipment which may assist you:
(a) in the recruitment process:
(b) to enable you to carry out the job:

Part 10 : Further Details

Please provide any information that you feel may support your application in the space below, e.g. personal qualities, experience gained in previous employment, training and development initiatives you have undertaken.

Part 11 : Declaration

Please tick this box to declare that the information on this form is correct to the best of your knowledge and belief. *

By ticking this box you agree and understand that false statements on this form may justify dismissal from Giffords Recycling Ltd.

Failure to agree to these terms and conditions will mean that you Job Application will NOT be accepted.