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APPLICATION FORM
Personnel Details
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date
*
Please select a month
January
February
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April
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Month
Please select a day
1
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Day
Please select a year
2025
2024
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1921
1920
Year
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Nationality
*
When are you available to start work?
*
-
Month
-
Day
Year
Date
National Insurance Number
Position
Position Applying For
Packer, Line Leader, QC ect.
Full Time or Part Time
Full Time
Part Time
If part time, please confirm what days you are available to work?
Have you worked for Valley Grown Salads or Valley Grown Nurseries before?
Yes
No
Right to Work
Do you have the Right to Work in the UK?
*
Yes
No
Share Code
Do you consent for a Right to Work check to be carried out?
*
Yes
No
Other
How were you referred to us?
Walk-In
A Friend
Facebook
Twitter
LinkedIn
Other (please specify)
CV, Identification Document, Any Licences (Forklift, HGV)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Do you have any of the following?
Valid First Aid Training
Valid Fire Warden Training
Forklift Licence - Please attach file
HGV Licence - Please attach file
Pre Booked Holiday Dates
Do you have any experience within the fresh produce industry?
Present or Most Recent Employment
Job Title
Start Date
-
Month
-
Day
Year
Date
Employer Name and Address
Reason for Leaving
Notice Period
Description of Duties
Education, Training and Qualifications
Medical Questionnaire
The tasks we carry out on site have been thoroughly assessed and the following questions are a result of the findings within our risk assessments. Areas of the company are temperature controlled; we restrict where possible the number of people working in these areas. We operate a strong hygiene program on site, and it is imperative that you declare when they have any period of sickness. It is not possible to predict who may be affected, so everyone must consider himself or herself at risk and take precautions. We operate the appropriate Person Protective Equipment (PPE) and controlled working in these areas. This could take the form of coveralls, hairnet, gloves which will be provided for you, but you are fully expected to comply when shown how to wear/use this type of equipment.
Do you suffer from or have you ever suffered from any allergies to plants or insects/bees?
Yes
No
Are you colour blind?
Yes
No
Do you suffer from or have you ever suffered from any respiratory problems?
Hayfever
Asthma
Bronchitis
Chest Infections
Other
Have you ever suffered from seizures?
*
Yes
No
Do you suffer from any skin diseases?
Dermatitis
Eczema
Proriasis
We limit how much individuals should lift/move and that bulk handling is done with pallet trucks and FLTs but the work we carry out on site is of a manual nature with long periods of standing, twisting, and lifting.
Do you have any pre-existing problems with your neck, back, shoulders, arms, wrists or feet?
*
Yes
No
The areas, which you would be required to work in, are exposed to hot temperatures
Are you able to work in these conditions safely?
*
Yes
No
Do you have any circulatory conditions such as:
Angina
Raynaud's Disease
Other heart conditions
Are you currently taking any prescribed medication?
*
Yes
No
Do you suffer from:
Diabetes
Thyroid Problems
Arthritis
Do you have any health conditions that you think may affect yours or the safety of others in the workplace?
Are you currently under the care of a doctor, consultant or another medical condition?
*
Yes
No
Next of Kin
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
The importance of disclosing any medical conditions prior to employment is paramount to ensure the safety of yourself and others around you. The information provided on this form will be used to; (i) Assess your medical capability to do the job for which you have been employed. (ii) To determine whether any reasonable adjustments may be required to accommodate any disability/impairment you might have. (iii) To ensure that none of the requirement of the job for which you have applied for would adversely affect any pre-existing conditions you may have.
Declaration
I, declare that the information I have given on this form is, to the best of my knowledge, true and complete. I understand that if it is subsequently discovered any information is false or misleading, or that I have withheld relevant information, my application be disqualified, or I may be dismissed due to the nature of the risk we have identified in the workplace. I hereby give my consent to the Company processing the data supplied on the application from for the purpose of recruitment and selection. However, should the need arise I also give consent to contact my GP if the information on this form requires further explanation. This also covered the need to maintain computer and paper records of my personal data which we process and store in accordance with the Data Protection Act 1998.
*
Submit Application
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