Candidate Registration | Linear Recruitment

Title

Surname

First Name

Email Address

Mobile Number

National Insurance Number

Address

Date Of Birth

Office

Interest In Permanent Roles

Interest In Temporary Roles

Interest In Contract Roles

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Accepted file types: pdf, doc, docx

Name of Contact

Relationship to You

Telephone Number

Do you have a valid driving license?

Yes

Do you have your own transport?

Yes

Have you ever been dismissed from an employer by being under the influence of alcohol/drugs?

Yes

If yes, please provide details

Do you have any unspent criminal convictions?

Yes

If yes, please provide details

Do you take regular medication or/have a medical condition that requires us to make reasonable adjustments to your place of work?

Yes

If yes, please provide details

Name of Company

Name of Manager

Address & Telephone Number

References

I consent to references being passed to potential employers

Bank Name And Address

Account Holder Name

Account Number

Sort Code

Signed

Have you been diagnosed with or are suffering from any medical condition/illness at the time of completing this questionnaire?

Yes

Are you taking regular medication?

Yes

Have you attended hospital or been admitted to hospital within the last year?

Yes

Do you suffer from fits / epilepsy?

Yes

Have you ever suffered blackouts, recurrant dizziness or any condition which may cause sudden collapse or incapacity?

Yes

Do you get discomfort or pain in the chest or shortness of breath on exercise? (e.g. climbing a single flight of stairs)

Yes

Do you have difficulty in moving rapidly over short distance on foot including slopes, steps or rough ground?

Yes

Do you have difficulty looking over either shoulder?

Yes

Do you have difficulty with your eyesight (other than wearing glasses or contact lenses being required)?

Yes

Do you have difficulty hearing normal conversation?

Yes

Are you taking any medication that is causing dizziness or drowsiness?

Yes

If you have answered 'yes' to any of the questions above please provide details:

Do you wear glasses?

Yes

Do you wear contact lenses?

Yes

Have you ever worked in a dusty or noisy environemnt?

Yes

Do you suffer from any other ailment?

Yes

Are you a smoker?

Yes

Are you registered disabled?

Yes

If you have answered 'yes' to any of the questions above please provide details:

If you have a disability, what are your needs in terms of reasonable adjustments to enable you to perform the role:

GP's name & surgery address:

Are you a prescribed medication by your doctor?

Yes

If 'yes' please list the details of each medication, the dosage you take along with the frequency of which you take it (once a day/twice a day/3 times a day etc):

I can confirm that I have given a true, accurate and honest record of my fitness to work and my medical status

All of the information I have provided Linear Recruitment with is correct to the best of my knowledge

I understand that providing incorrect or false information could result in the termination of my contract with Linear Recruitment

I consent to the details enclosed on this form being shared with a medical professional (for example a doctor) in the case of an emergency

I understand that if there are any changes to my medical sitation on this self-assessment medical questionnaire, I must inform Linear Recruitment immediately

Signed

I confirm that I have read and agreed to the

Signed

I confirm that I have read and agreed to the

Signed

I confirm that I have read and agreed to the

Signed

I confirm that I have read and agreed to the

Signed