Reference Number*

Your Name

MrMrsMissMs

First Name*

Last Name*

Preferred Name

Position Applied for*

Country*

Site*

Address (Postal)*

Telephone Number

Mobile Number

Your Email*

Motor Vehicle Licence No

Classes of licence held

Education:

Name of Secondary school(s) attended. Include University and further education and highest Qualification achieved*

Other Courses, or qualifications

Please list any other skills or abilities you have that may relate to the job applied for.

Upload your CV

Upload your Reference

Status:

1. Are you legally entitled to work in the country you have applied for the position(If on a work permit a copy of the original work permit will need to be supplied)

 

YesNo

2. Date of Birth

   

Employment History:

Most recent employer first.

1. Date from

to

Company

   

Job held:

   

Duties

       

2. Date from

to

Company

   

Job held:

   

Duties

       

3. Date from

to

Company

   

Job held:

   

Duties

General

1. Have you ever worked for Pedersen Group before?

YesNo

if Yes, when and in which location/division?

2. Do you know anyone working for Pedersen Group ?

YesNo

If yes, names:

3. Are you able to work shifts seven days a week ?

yesNo

4. Are you prepared to work over time if required?

YesNo

5. Do you have any de-merit or endorsements/convictions against your licence?

YesNo

If yes, give details please:

Previous Conduct

1. Have you ever been convicted of a criminal offence?
Your attention is drawn to the Clean Slate Act

YesNo

2. Are you awaiting the hearing of charges in a civil or criminal court of law?

YesNo

If yes to Questions 1 or 2 above, please comment:

Medical

1. If you have ever been diagnosed with any of the conditions listed below please tick the box relating to the condition or disease.

Heart disease or surgery

Epilepsy / Fits

Anxiety or Depression

Asthma or Bronchitis

Chest pain, Angina

Head injury, Concussion

Deafness, Loss of hearing

Hernia

Tuberculosis (TB)

High blood pressure

Dizzy spells or Blackouts

Psychiatric illness

Hepatitis

HIV

Neck injury, Whiplash

Colour blindness

Knee problems, cartilage

Pneumonia

Haemophilia

Diabetes

Dyslexia

RSI, Tenosynovitis, Wrist strain,

Arthritis/Rheumatism

Back pain, Sciatica, Lumbago, slipped disc

Stroke

High Cholesterol

Pleurisy

Have you ever had any condition or Illness that has required that you be hospitalised or have more than 5 days off work

YesNo

If the answer is Yes Please Provide Details

Have you ever worked in any of the following jobs:-

Mining, tunnelling or quarrying

In a smelter

Furniture or woodworking trade

With clutch or brake linings

Grinding

Any timber industry

Welding

Building trade

Foundry work

With plastics, resins or paints

Asbestos / textile factory

Floor sander

Have you ever been regularly exposed to:-

Loud noise

Radiation

Asbestos

Other dusts

Chemicals

 

If yes, please comment:

2. For the position you applied for you may be required to wear protective clothing. Have you any illness, injury or disability which may affect your ability to wear protective clothing and therefore affect your ability to perform the job for which you have applied for?

Dermatitis, Eczema, Skin Problems

Allergies

If yes, please comment:

3. Have you ever had any lost time accident or time off work as the result of a work related accident

YesNo

If yes, please comment:

4. Are you allergic to, have any sensitivity to any substances, chemicals or drugs?

YesNo

If yes, please comment:

5. Does any medical (including mental and physical) condition you have require you to take any prescription medication.

YesNo

If yes, please answer the following:

a) Does any prescription medication you take have any side effects that might affect your performance in this position?

YesNo

b) If you answered yes to the above, what is the expected length of time over which you will be required to take the medication?

6. Do you suffer from any vision impairment or require corrective Lenses (glasses) contact lenses? or colour blindness?

YesNo

If yes, please comment as to when it is necessary for you to wear these:

7. Pedersen Group , in the interest of Employee Health & Safety, has put in place an
Drug and Alcohol testing programme.
Pedersen Group operate drug and alcohol free work sites.
This Drug and Alcohol programme is set out in more detail in the Company Policy/Procedure – Drug & Alcohol. A pre-employment medical examination including a drug test is compulsory and it is to be undertaken by a medical professional appointed by us.

Do you agree to undergo a medical examination, health checks? And drug/alcohol testing in accordance with the Company's Drug and Alcohol Policy/Procedure.

YesNo

Privacy

The information you have provided throughout the employment application procedure (the information") will be used for the purposes of deciding whether to employ you and will be held by Pedersen Group. You have the right of access to request correction of the information.

Employee Declaration

1. I authorise Pedersen Group to use the information in this application for the purposes connected with the recruitment and, if I am employed, to use all information held about me for all purposes connected to my employment.

2. Pedersen Group is relying on the information provided in this document to make decisions relating to your suitability for employment. If at any future date it is found and proven that you have provided incorrect information or failed to disclose any relevant information on this form then it may provide grounds for your termination .