Registration Form (PLEASE COMPLETE IN BLOCK CAPITALS)
PAYE Worker
What is your Full Name?
*
First Name
Last Name
Which Branch are you registering with?
*
Please Select
Bishop Auckland
Bristol
Cardiff
Crewe
Croydon
Derby
Doncaster
Eastleigh
Feltham
Leeds
Leyland
Manchester
Milton Keynes
Northampton
Reading
Runcorn
Sheffield
St Albans
Swindon
Tamworth
Wolverhampton
Worcester
How did you hear about Drivers Direct?
*
Advert
Referral
Passer By
Worked for us in the past
Other
What is your Preferred Type of Work?
*
Driving
Industrial
Other
What is your Date Of Birth?
*
/
Day
/
Month
Year
What is your Age?
*
What is your Gender?
*
Male
Female
Prefer not to say
Other
Date Registered
/
Day
/
Month
Year
What is your Permanent Address?
*
Street Address
Street Address Line 2
Town / City
County
Post Code
What is your N.I. Number?
*
What is your Nationality?
*
Emergency contact name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: 00000 000000.
What is your Email address?
*
Please enter a valid email address.
What is your preferred shift pattern?
Full Time
Part Time
24 Hours
Days
Nights
What is your Phone Number?
Please enter a valid phone number.
Format: 00000 000000.
What is your Mobile Number?
*
Please enter a valid phone number.
Format: 00000 000000.
Do you have your own transport?
Please Select
YES
NO
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BANK DETAILS
Please provide the details of the bank account that you wish to be paid into
Bank / Building Society Name
*
Bank Location
Sort Code
*
Account Number
*
Account Holder's Name
*
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YOUR EXPERIENCE
In this section, please tick the relevant boxes if you have experience in the following:
Class of LGV
Class 1 (C+E)
Class 2 (C)
PCV
7.5 Tonne
3.5 Tonne
Light Van
Total Years LGV Experience
please tick the relevant boxes if you have experience in the following
Tachograph
Multidrop
ADR
HIAB
Nights Out
Draw Bar
Digi Card
Car Transporters
Double Deckers
Flat Beds
General Haulage
Tippers
Skips
Fridges
Curtain Side
Rope & Sheet
Chain & Toggle
Forklift
Union Ticket
Sat Nav
What date did you pass your LGV Test?
/
Day
/
Month
Year
What Makes of Vehicles have you driven in the past?
What types of Gearbox are you familiar with?
Automatic
Range Change
Splitter
Other
What Geographical areas are you familiar with?
What is your Driving Licence Number?
*
Industrial Work (Tick as applicable)
General Warehousing
Picking
Fork Lift
Reach Truck
Line Work
Operating
Driver's Mate
Removals
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EMPLOYMENT HISTORY (LAST THREE YEARS)
In this section, please supply your employment history, most recent first. You need to provide at least one previous employer.
Last Employer - Company Name
*
Last Employer - Contact Name
*
Last Employer - Address
*
Last Employer - Contact Number
*
Please enter a valid phone number.
Format: 00000 000000.
Last Employer - Approximate start and end dates
*
Last Employer - Duties
*
Last Employer - Reason For Leaving
*
Previous Employer 1 - Contact Name (optional)
Previous Employer 1 - Company Name
Previous Employer 1 - Address
Previous Employer 1 - Contact Number
Please enter a valid phone number.
Format: 00000 000000.
Previous Employer 1 - Approximate start and end dates
Previous Employer 1 - Duties
Previous Employer 1 - Reason For Leaving
Previous Employer 2 - Contact Name (optional)
Previous Employer 2 - Company Name
Previous Employer 2 - Address
Previous Employer 2 - Contact Number
Please enter a valid phone number.
Format: 00000 000000.
Previous Employer 2 - Approximate start and end dates
Previous Employer 2 - Duties
Previous Employer 2 - Reason For Leaving
References
Please provide details for at least one referee
Please provide a Reference Contact Name
*
Please provide an address for your reference
Please provide a contact number for your reference
*
Please enter a valid phone number.
Format: 00000 000000.
Reference 2 - Contact Name (optional)
Reference 2 - Address
Reference 2 - Contact Number
Please enter a valid phone number.
Format: 00000 000000.
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DECLARATION TO BE COMPLETED BY ALL APPLICANTS
Please answer the below questions.
Have you at any time in the past 5 years been convicted of any offences?
*
YES
NO
Have you during the last ten years had your licence suspended?
*
YES
NO
At the date of signing this form, is there any prosecution pending, or has anything occurred which may result in a future prosecution?
*
YES
NO
Have you, to your knowledge, any physical or mental defects or infirmity or do you suffer from diabetes, heart complaints or any other disease which may impair your driving ability or your ability to carry out your duties whilst taking reasonable steps to safeguard your own safety and the safety of any other person who may be affected by your actions at work?
*
YES
NO
If YES to any of the above, please give details below
*
I confirm my understanding and agreement of the above
*
AGREE
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HEALTH QUESTIONNAIRE
Name and Address of your Family Doctor
If you have suffered from any of the following, please tick the relevant box - It is imperative that all questions are answered honestly to ensure that all applicants are treated fairly and that reasonable adjustments can be considered
Registered Disabled
Surgical Operation
Serious Injury / Fracture
Rheumatic Fever
Heart Trouble
Bad Circulation
High Blood Pressure
Frequent Colds or Sore Throats
Pneumonia or Bronchitis
Asthma
Hay Fever
Allergies
Tuberculosis
Other Chest Illness (Please Specify Below)
Chest Disorders, especially if troublesome at night
Severe or Frequent Indigestion
Stomach Troubles
Hernia (Rupture)
Kidney or Bladder Troubles
Any medical condition that might affect fitness at work
Dermatitis
Other Skin Disease (Please Specify Below)
Severe or Frequent Blackouts
Faints or Blackouts
Eplisepsy
Varicose Veins
Backache or Pain
Neck ache or Pain
Wrist ache or Pain
Arthritis
Rheumatism
Joint / Muscle Troubles
Hearing or Ear Problems
Jaundice
Any medication requiring adherence to a strict timetable
Depression or Illness
Industrial Disease / Injury (Please Specify Below)
Eye Abnormality
Contact Lenses
If you have answered "yes" to any questions, you may be asked to see a doctor for assessment
If you ticked any of the above, please give details below
Have you had any time off work due to illness or Injury in the last two years? If YES, please give details
*
NO
YES (please give details)
How many work days have you lost in the last two years due to illness or injury?
*
Do you have to take one or two days off work regularly each month? If YES, please give details
*
NO
YES (please give details)
Have you ever had to change your job because of your health? If YES, please give details
*
NO
YES (please give details)
Are you under any form of treatment or medical supervision at present? If YES, please give details
*
NO
YES (please give details)
Are you pregnant? If so, how many months? (This question to be answered if the proposed contract constitutes a hazard to pregnant women)
*
NO
YES
Have you a problem or a history of difficulty in sleeping? If YES, please give details
*
NO
YES (please give details)
I confirm my understanding and agreement of the above
*
AGREE
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Please select one option
*
I AM NOT currently engaged in any other work
I AM currently engaged in other work (please provide details)
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Please read and confirm your understanding and agreement of the above
*
AGREE
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Please confirm that you have received the handout described above
*
AGREE
Please sign here with you normal signature to confirm that you have read and understood all of the information given to you and that all of the information you have provided is correct.
*
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Submit your registration
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