Job Application: HGV Driver
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- Irma Drusilla Sparks
- 6 years ago
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1 Job Application: HGV Driver 1. Full Name 2. Address including postcode 3. How many years resident in the UK 4. Telephone numbers (landline and mobile please) 5. What type and class of licence do you hold? 6. How long have you held your licence in the above class? 7. Please give the date you passed your driving test 8. What is the number of your licence? 9. Please state the types of vehicles you have driven and for what periods: Car Transporter Other articulated vehicles P.S.V.'s Units over 10 ton with trailers Other units over 10 ton Other HGV's (please give details) Page 1
2 10. Who were your employers during the periods you have driven professionally? From To Name and address of employer Job title Reason for leaving 11. Have you ever been charged with and/or convicted of any motoring offence? If so, give dates and results of prosecutions. 12. Is any prosecution pending? 13. Give details of ALL accidents, claims or losses which have occurred in the last TEN years in connections with any vehicle owned or driven by you (whether you were at fault or not). Date Details of accident 14. Have you ever been convicted of a criminal offence? (declaration subject to the Rehabilitation of Offenders Act) 15. What are your interests/hobbies? Page 2
3 Employee Health Records Strictly Private and Confidential It is now a statutory requirement under the Health & Safety at Work Act 1974 and in particular the COSHH Regulations of 2002 (Regulation 11) "that for the protection of the health of his employees, collect, keep up to date and use data and information for determining and evaluating hazards to health". It is also required that all such records are retained for a minimum of 40 years. We would confirm that all information will be stored safely and subjected to the highest degree of confidentiality. MEDICAL HISTORY; Have you ever in your life, including childhood, had any of the following? Asthma Bronchitis Pneumonia Pleurisy Persistant cough or sputum Tuberculosis Heart disease or disorder(including pain in chest on exertion, high blood pressure palpitations, shortness of breath) Disorder of blood or circulation (including Raynaud's disease and "white finger") Gastric disorder or stomach trouble Diabetes Giddiness or fainting attacks Epilepsy or blackouts Headaches or migraine Have you ever had your lung function checked? Hernia, rupture Arthritis (specifically rheamatoid or osteo) Lumbago or fibrositis Recurrent backache Recurrent backache sciatica Any allergy/sensitisation Any skin disease, eczema, dermatitis Any eye disease of disturbance of vision Any ear disease or hearing problem Any other illness or disability Are you presently taking any prescription injections or medicines? Have you ever had a chest x-ray? If so give date and result. Have you ever claimed a disability pension or industrial injury benefit? No Yes Remarks (including dates of attacks and duration) Page 3
4 PLEASE READ THE FOLLOWING AND THEN ADD YOUR SIGNATURE AT THE BOTTOM OF THE PAGE I certify that the particulars given on this form are correct and that it is a condition of my acceptance of any offer of employment as Heavy Goods Vehicle Driver that I am prepared to: (a) Operate within the law (b) Stay out overnight as and when required ( c) Work Saturdays/Sundays as and when required (d) Do early starts as and when required (e) Certify any claim for Tax Free Subsistence on the Inland Revenue agreed form (f) Notify my employer of any change in circumstances (g) Be paid directly into my bank or building society (h) Follow the instructions in the Drivers' Manual I understand that it is a condition of my employment that:- 1. I hold a current HGV licence 2. I will not falsify tachograph records 3. The particulars on this form are true. Any deception or failure to comply will automatically terminate my employment with the Company without compensation or redundancy. No monies will be paid in lieu of notice unless: 1. A weeks notice is given prior to leaving. 2. All equipment issued is returned to the Traffic Office. 3. Your digital tachograph is downloaded. 4. The vehicle is left in a clean and tidy condition. Signed Date Page 4
5 PERSONNEL RECORDS The following section is to be completed only when an offer of employment has been made & accepted. P1. National insurance number OFFICE USE P2. Date of birth P3. Please give details of a person who we may contact in an emergency: Name: Telephone number: Relationship to you: P4. Your wages will be paid directly into your bank account, please give details. Ensure that these numbers are correct as mistakes may delay your payment. Bank name: OFFICE USE Branch address: Auto: Sort Code: (6 digits) Account no: (8 digits) P5. Holiday commitment this year PLEASE ENCLOSE COPIES OF THE FOLLOWING DOCUMENTS: OFFICE USE Current driving licence (photo and paper) Any current training certificates you hold Office use only Emp no: DOS: Page 5
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1421 S. Potomac Street, Suite 120 Aurora, CO Please print and complete all parts.
Thomas J. Savage, DPM Jay H. Dworkin, DPM PC 1421 S. Potomac Street, Suite 120 Aurora, CO 80012 303.923.3369 www.metrofoot.org 303.923.3882(fax) Please print and complete all parts. Date PATIENT INFORMATION
Family Medicine Center of the Bitterroot, P.C.
PATIENT REGISTRATION / FINANCIAL AGREEMENT Thank you for taking time to complete this form. This information is necessary for the preparation of your clinic records. You are responsible for all charges
Registration Form. Gender: Male Last Name First Name Middle Initial Female. - - / / Social Security Number Date of Birth Age Occupation / Employer
Registration Form General Information Have you been treated by us before? Yes No Gender: Male Last Name First Name Middle Initial Female Social Security Number of Birth Age Occupation / Employer Street
PATIENT INFORMATION. Middle Name: First Name: DOB: Sex: Male/Female Marital Status: married/single/divorced/widowed HOME ADDRESS.
PATIENT INFORMATION Last Name: Middle Name: First Name: DOB: Sex: Male/Female SS# Marital Status: married/single/divorced/widowed HOME ADDRESS Address (include apt. #): City: State: Zip: Home Phone: Cell:
KORT New Patient Information
KORT New Patient Information Patient Address: City/State/Zip: E-Mail Address: Date of Birth: / / Age: Sex: Social Security Number: - - Marital Status: Home Phone: Cell phone: Employer/School: Employer