SUPPLIER /SUBCONTRACTOR VETTING FORM
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1 THIS FORM MUST BE COMPLETED BY BONA-FIDE SUB-CONTRACTORS AND LABOUR ONLY SUB-CONTRACTORS. PLEASE PRINT, COMPLETE AND RETURN THIS DOCUMENT BEFORE COMMENCEMENT OF WORK ON SITE. PLEASE ENSURE THAT ANY ADDITIONAL SHEETS ARE MARKED CLEARLY WITH YOUR NAME. THE RED SECTIONS ARE MANDATORY. 345 INTERIORS LIMITED COMPLETED FORM TO OR SEND BY POST SUITE OLD BAILEY LONDON EC4M 7EF FIRST NAME SURNAME TRADING AS (LEGAL NAME) FULL ADDRESS POST CODE TEL MOBILE ADDRESS WEBSITE OF BIRTH (Sole Trader) TRADE WORKING STATUS CIS REGISTERED CIS/UTR NUMBER VAT NUMBER LTD COMPANY UTR BANK NAME ACCOUNT NUMBER DIRECTORS NAMES NATIONALITY (Sole Trader) DO YOU NEED A WORK PERMIT TO BE EMPLOYED IN THE UK? (Sole Trader) WHERE DID YOU LEARN OF THIS POST? N.I NUMBER (Sub-Contractor only) OF REGISTRATION COMPANY REG. SORT CODE BENEFICIARY NAME PLEASE PROVIDE A GOOD QUALITY PHOTOCOPY OF BOTH SIDES OF YOUR CIS CARD AND PROOF YOUR NATIONAL INSURANCE NUMBER. IF TRADING AS A LTD COMPANY OR VAT REGISTERED, PLEASE PROVIDE PHOTOCOPY OF YOUR REGISTRATION CERTIFICATES PLEASE PROVIDE A COPY OF YOUR HEALTH AND SAFETY POLICY AND PROCEDURES PRIMARY TRADE YEARS IN TRADE SKILLS / EXPERIENCE / PREVIOUS PROJECTS SUB-CONTRACTOR / COMPANY / PARTNERSHIP / If you are not a British passport holder or a European citizen, or you do not have a permanent right to remain in the UK, you will require a work permit. If you already have a work permit when does it expire? (Please note that your current work permit may not be valid for this post) HIGHEST QUALIFICATION ACHIEVED PROVIDE DETAILS AND EVIDENCE OF TRAINING PROVIDED FOR STAFF DO YOU EMPLOY SUB-CONTRACTORS? IF PLEASE CONFIRM THAT YOU HAVE A PROCESS FOR SUB-CONTRACTOR VETTING 345 Interiors Ltd 345_SVF 1 of 5
2 PROVIDE TWO TRADE REFERENCES TO BE CONTACTED CONTACT NAME (SITE MANAGER/CLIENT) WORK COMPLETED/SERVICES PROVIDED PROJECT START VALUE OF PROJECT CONTACT TELEPHONE CONTACT ADDRESS GENDER (Sole Trader) MALE MARITAL STATUS (Sole Trader) MARRIED DIVORCED SINGLE WIDOWED SEPARATED OTHER ETHNIC ORIGIN (Sole Trader) WHITE BRITISH BLACK/BLACK BRITISH CHINESE WHITE IRISH ASIAN/ASIAN BRITISH OTHER: WHITE OTHER MIXED AGE RANGE (Sole Trader) FEMALE (THE ABOVE INFORMATION IS REQUESTED FOR COMPANY EQUAL OPPORTUNITIES RECORDS AND WILL T BE SHARED OR USED FOR ANY OTHER PURPOSES) 2 DO YOU HAVE ANY OF THE FOLLOWING TRAINING? (PLEASE TE THAT TRANING CAN BE ARRANGED THROUGH 345 INTERIORS. PLEASE CALL FOR FURTHER DETAILS) CSCS CARD - COMPULSARY FOR ALL OPERATIVES PASLODE OPERATIVE - COMPULSORARY IF USING NAIL GUNS BANKSMAN/SLINGER SSSTS (SITE SUPERVISOR TRAINING SCHEME) SMSTS (SITE MANAGER SAFETY TRAINING SCHEME) PASMA FIRST AID ASBESTOS AWARENESS FIRE MARSHALL PTS TRAINING - COMPULSORY FOR WORKING IN RAIL OTHER, PLEASE DETAIL ON A SEPARATE SHEET RECEIVED EXPIRES PLEASE PROVIDE GOOD QUALITY PHOTOCOPIES OF YOUR TRAINING CERTIFICATES PUBLIC LIABILITY INSURERS LEVEL OF COVER HAVE YOU MADE ANY CLAIMS IN THE PAST 5 YEARS? IF, PLEASE GIVE DETAILS POLICY NUMBER RENEWAL PLEASE PROVIDE GOOD QUALITY PHOTOCOPIES OF YOUR PUBLIC LIABILTY INSURANCE CERTIFICATE ACCIDENT RECORDS AND HISTORY (ORDER BY MOST RECENT) DETAILS RIDDOR REPORTABLE / PLEASE PROVIDE A COPY OF AN EXAMPLE RISK ASSESSMENT / METHOD STATEMENT FOR WORKS SIMILAR TO THOSE REQUESTED ALL PORTABLE POWER TOOLS USED ONSITE ARE REQUIRED TO BE PAT TESTED REGULARLY. SPOT CHECKS WILL BE CARRIED OUT ON ALL SUBCONTRACTORS. PAT TESTING CAN BE ARRANGED THROUGH 345 INTERIORS LTD. PLEASE CALL FOR DETAILS. ARE YOUR TOOLS REGULARLY PAT TESTED (PORTABLE APPLIANCE TESTING)? PLEASE PROVIDE GOOD QUALITY PHOTOCOPIES OF YOUR APPLIANCE TESTING RECORDS/CERTIFICATES DO YOU HAVE A DISABILITY WHICH MAY AFFECT YOUR ABILITY TO UNDERTAKE YOUR DUTIES OR WHICH REQUIRES SPECIAL REQUIREMENTS? IF PLEASE GIVE DETAILS 345 Interiors Ltd 345_SVF 2 of 5
3 HAVE YOU EVER HAD ANY OF THE FOLOWING? 1 Epilepsey, fits blackouts fainiting turns or unexplained loss of consciousness 2 Vertigo,dizziness,giddiness,problems with balance 3 Recurrent headache or migrane 4 Diseases of the nervous system eg. Neuritis, stroke 5 Chest pain,angina,heart disease or breathlessness 6 Any visual defect eg. Scotma,blindness in one eye, reduced visual field blurred vision or colour blind 7 Raised or low blood pressure 8 Any blood disorder 9 Astma, bronchitis,emphysema, pneumonia or lung disease DETAILS HAVE YOU EVER HAD ANY OF THE FOLOWING? DETAILS 10 Jaundice or any form of hepitias or liver problem 11 Kidney or bladder conditions 12 Arthritis, gout or rheumatism 13 Any metabolic disorder including diabetes thyroid and adrenal gland disease 14 Psoriasis, eczema, allergic skin rash or other skin disorder 15 Any infectious diseases 16 Anxiety/depression, mental breakdown or stress related problems 17 Substance missuse 18 Any allergies including hay fever 19 Any malignancies or cancers 20 Any operations or surgical procedures 21 Ear or hearing problems 22 Any other medical condition 23 Have you ever consulted a orthopaedic surgeon, chiropractor, osteopath or physiotherapist 24 Are you currently attending a hospital/gp for treatment or waiting for an appointment HAVE YOU EVER LEFT A JOB OR BEEN MEDICALLY RETIRED DUE TO ILL HEALTH? IF PLEASE GIVE DETAILS HOW MUCH ALCOHOL ON AVERAGE DO YOU CONSUME DURING A SEVEN DAY PERIOD (1 UNIT= 1/2 PINT BEER/ 1 GLASS OF WINE/ 1MEASURE OF SPIRITS)? UNITS DO YOU HAVE A CRIMINAL RECORD? IF, PLEASE PROVIDE DETAILS HAVE YOU EVER ATTENDED AN EMPLOYMENT TRIBUNAL? IF, PLEASE PROVIDE DETAILS HAVE YOU EVER BEEN REMOVED FROM SITE DUE TO BREACH OF HEALTH AND SAFETY? IF, PLEASE PROVIDE DETAILS HAVE YOU EVER BEEN REMOVED FROM SITE FOR ANY OTHER REASON? IF, PLEASE PROVIDE DETAILS 345 Interiors Ltd 345_SVF 3 of 5
4 DECLARATION I declare that the information given above is true and complete. I understand that any misleading information or omissions will be sufficient grounds for removal from site. I will notify you immediately if any of my answers on the above questionaire change. I understand that the information provided will be held in my confidential file on paper or computer and will only be used for health and safety purposes. PRINT NAME SIGNATURE OFFICE USE ONLY: DOCUMENTS RECIEVED DOCUMENTS VERIFIED REF 1 CONTACTED REF 2 CONTACTED COPY OF REPLY ATTACHED COPY OF REPLY ATTACHED ACCOUNT SET SUBCONTRACTOR REF PRINT NAME SIGN 345 Interiors Ltd 345_SVF 4 of 5
5 CONTINUATION SHEET FULL NAME CONTINUATION PAGE OF PRINT NAME SIGN TRADING AS NAME 345 Interiors Ltd 345_SVF 5 of 5
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