image
Wash Bay Staff Application Form

Please note: all fields are required except for Date of Birth. If no fields are applicable, then please enter "N/A"

Section 1 - Applicants Personal Details

Forename(s)
Surname
Home Address
Date of Birth (DD/MM/YYYY) (Optional) / /
Nationality
Home Tel No. (incl. STD code)
Mobile Tel No.
Email Address
Marital Status
Number of dependants


Section 2 - Previous Employment History

a) Employer Name
Period of Employment from

to
Reason for leaving
Position held
How many months tanker experience gained?
Name of Referee
Referee's Tel. No. (incl. STD code)
   
b) Employer Name
Period of Employment from

to
Reason for leaving
Position held
How many months tanker experience gained?
Name of Referee
Referee's Tel. No. (incl. STD code)
   
c) Employer Name
Period of Employment from

to
Reason for leaving
Position held
How many months tanker experience gained?
Name of Referee
Referee's Tel. No. (incl. STD code)

IF YOU DO NOT WANT US TO CONTACT ANY OF THE ABOVE REFEREES UNTIL YOU ARE OFFERED A POSITION THEN PLEASE INDICATE THIS ABOVE.



Section 3 - Relevant Qualifications
Please note any relevant qualifications such as First Aid Cert, CPC, Road Safety Course etc

a) Course Name/Award
Dates of Study from

to
Place of Study
   
b) Course Name/Award
Dates of Study from

to
Place of Study


Section 4 - Other Information

Driving Licence No.
LGV Expiry Date (DD/MM/YYYY) / /
Details of any endorsements
Hazchem Certificate No. (if held)
Expiry Date / /
Details of any criminal convictions (Declaration subject to the rehabilitation of Offenders act 1974)
When you are available to start with ART?


Section 5 - Medical Questionnaire
The information in this section will be kept private & confidential and will be used to protect the health of yourself and others.  Any points of uncertainty can be discussed at your interview.

Please tick relevant boxes

 
YES
NO

a) Any circulatory problems such as varicose veins, phlebitis or thrombosis?
b) Any heart problems such as angina, high blood pressure or heart attacks?
c) Any chest problems such as asthma?
d) Diabetes?
e) Epilepsy or fainting attacks?
f) Skin disorders?
g) Recent operation or fractures?
h) Are you currently taking any medications?
i) Back trouble, arthritis, rheumatism?
j) Injury to bones, joints, tendons, including wrist tendons?
k) Any other work related upper limb disorders?
l) Any claims for work related injuries, illness etc in the past?
m) Coughing fits?
n) Have you worked in an industry with high noise levels?
o) Have you or any member of your family had a history of mental disorder?
p) Any other significant health problems?


Please select depot you prefer to work from

I confirm that the details on this Application Form are true and understand that submission of false information may lead to instant dismissal if employment is offered.