Please note: Any field marked with a * must be completed before the form can be submitted. If at the end you click to submit and you do not see a confirmation message then a field is not completed and will be highlighted with a red frame on the form. PERSONAL PARTICULARS Surname * Forename(s) * Postal Address * Email Address Home Telephone Number Mobile Telephone Number * National Insurance Number * Date of Birth * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009 Marital Status No of Children Height * Weight * Do you have the legal right to live and work in the UK? NOTE: If invited for interview you will need to bring original documents (See link for list: https://www.gov.uk/government/publications/right-to-work-checklist) in order for us to copy to prove your right to work. * Yes No HEALTH DETAILS Are you in good general health? * Yes No Do you meet DVLA medical standards for driving, including hearing and eye sight ? * Yes No Have you now, or ever had, any physical mobility impairment ? (specifically, we are seeking to clarify your capability to undertake the physical requirements of our work, including, for example, the repeated access, ascent and descent of vehicle steps and tank ladders on multiple occasions throughout the working day). * Yes No Have you had medical attention in the last 5 years ? * Yes No Are you required to take regular medication ? * Yes No How much absence from work did you have last year ? * Are there other health matters an employer should be aware of ? List any DVLA notifiable conditions. See https://www.gov.uk/health-conditions-and-driving for details. * Are you allergic to penicillin (or any other medication (please list)) * Yes No If yes to any medical question above, then please give details below LICENCE PARTICULARS (We only operate Class 1/LGV so require this licence) Driving Licence Number * Car Driving Licence Valid From * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 Car Driving Licence Valid To * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096 Please confirm your HGV Driving Licence Class is Class 1 * Yes No HGV Driving Licence Valid From * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 HGV Driving Licence Valid To * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096 List & date any endorsements (if none state none) List any details of pending convictions (if none state none) List any details of Accidents in the past 3 years (if none state none) May we have your permission to go online and check the licence details which the DVLA hold for you ? You can do this yourself and give us a current, valid Check Code - visit https://www.gov.uk/view-driving-licence * Yes No If you answered ‘No’, please supply a valid check-code ADR Licence Valid From * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year2020202120222023202420252026 ADR Licence Valid To * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year2026202720282029203020312032 ADR Classes – Tanks * 1 2 3 4 5 6 7 8 9 ADR Classes – Other Than Tanks 1 2 3 4 5 6 7 8 9 CPC TRAINING CPC Licence Valid From * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year2020202120222023202420252026 CPC Licence Valid To * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year2026202720282029203020312032 Course Titles Total CPC Hours toward next renewal gained Have these CPC Hrs been uploaded? Yes No DRIVING & ADR EXPERIENCE How many years of LGV1 experience do you have * How many years of experience have you had in General Haulage How many years of experience have you had in Container Haulage How many years of experience have you had in Compartment Tankers How many years of experience have you had in Chemical Tankers List any Hazardous Chemicals that you are used to handling : Note any additional comments and/or details of experience below : PREVIOUS EMPLOYMENT Job 1 - Company Name (Most recent) Job 1 - Contact Name Job 1 - Contact Title Job 1 - Is the above contact a referee Yes No Job 1 - Start Date Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 Job 1 - Job Description Job 1 - Leave Date Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year202120222023202420252026 Job 1 - Reason For Leaving Job 2 - Company Name Job 2 - Contact Name Job 2 - Contact Title Job 2 - Is the above contact a referee Yes No Job 2 - Start Date Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year1996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 Job 2 - Job Description Job 2 - Leave Date Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year1996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 Job 2 - Reason For Leaving Job 3 - Company Name Job 3 - Contact Name Job 3 - Contact Job Title Job 3 - Is the above contact a referee Yes No Job 3 - Start Date Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year1996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 Job 3 - Job Description Job 3 - Leave Date Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year1996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 Job 3 - Reason For Leaving OTHER DETAILS Are you a good timekeeper ? * Yes No Are you applying to work night-shift ? * Yes No Are you willing to undertake nights out in a sleeper cab, sometimes at short notice ? * Yes No What amount of nights out per shift pattern would suit you? Please state you preference from the options below * - Select - 0 1-2 2-3 4-5 Any All new starters normally work on a rolling week shift pattern. Please state your preference from the options below * - Select - 6 on 2 off 5 on 3 off 4 on 4 off Ad-hoc part-time Any List any experience of working shifts, night-out work or unusual work patterns List any supplementary details that may assist your application : i.e. relevant training / certificates Are you willing to undertake a DBS check if successful with your application ? * Yes No
