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 .