New Starter Checklist

Clock Card Number*

Factory/Dept*

Section*

First name(s)*

Last name or family name*

Are you male or female?*

Date of birth dd/mm/yyyy

Address*

Town*

Postcode*

Home telephone Number*

Mobile telephone number

Email address*

National Insurance Number*

Employment start date dd/mm/yyyy*

Bank name*

Name of account holder*

Sort code*

Account number*

Rate of pay p/h*

Please select only one of the following statements*

This is my first job since last 6 April and I have not been receiving taxable Jobseeker’s Allowance, Employment and Support Allowance, taxable Incapacity Benefit, State or Occupational Pension. This is now my only job but since last 6 April I have had another job, or received taxable Jobseeker’s Allowance, Employment and Support Allowance or taxable Incapacity Benefit. I do not receive a State or Occupational Pension. As well as my new, I have another job or receive a State or Occupational Pension.

I have a Student Loan which is not fully repaid and I left a course of UK higher education before last 6 April andreceived my first Student Loan instalment on or after 1 September 1998.

Select ‘No’ if you are repaying your Student Loan direct to the Student Loans Company by agreed monthly payments.

Student Loan*

Yes No N/A

Contact 1 Name*

Contact 1 Number*

Contact 1 Email Address

Contact 2 Name*

Contact 2 Number*

Contact 2 Email Address

Please answer the following questions. If the answer is YES then please provide full details.

Name of Doctor

Address

City

Postcode

Allergies*

Yes No

Asthma*

Yes No

Hay Fever*

Yes No

Cardiovascular

Chest Pain*

Yes No

Heart Disorder*

Yes No

High Blood Pressure*

Yes No

Palpitations*

Yes No

Rheumatic Fever*

Yes No

Digestive System

Hernia*

Yes No

Jaundice*

Yes No

Peptic Ulcer*

Yes No

Rectal Bleeding*

Yes No

Neurological

Dizzy Spells*

Yes No

Epilepsy*

Yes No

Fainting Attacks*

Yes No

Paralysis*

Yes No

Severe Headaches*

Yes No

Genito-Urinary

Kidney Stones*

Yes No

Pain on Urination*

Yes No

Sugar/Albumin Urine*

Yes No

Respiratory

Chronic Cough*

Yes No

Pleurisy*

Yes No

Pneumonia*

Yes No

Sinusitis*

Yes No

Tuberculosis*

Yes No

Musculoskeletal

Arthritis*

Yes No

Backache*

Yes No

Back Injury*

Yes No

Disc Disorder*

Yes No

Gout*

Yes No

Joint/Tendon Disorder*

Yes No

Rheumatism*

Yes No

Senses

Colour Blindness*

Yes No

Ear Disorder*

Yes No

Eye Disorder*

Yes No

Nose Disorder*

Yes No

Throat Disorder

Yes No

Speech Disorder*

Yes No

Dyslexia*

Yes No

Miscellaneous

Anaemia*

Yes No

Anxiety*

Yes No

Blood Disorder*

Yes No

Cancer*

Yes No

Depression*

Yes No

Diabetes*

Yes No

General Debility*

Yes No

Insomnia*

Yes No

Skin Disorder*

Yes No

Dermatitis*

Yes No

If YES, please give full details

I understand that misrepresentation, falsification or omission of information requested on this application form may be a reason for dismissal

Full name*

Date dd/mm/yyyy*