DELTA ONE SECURITY SERVICES LTD

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1 Delta House, Pilgrims Way, Bede Industrial Estate, Jarrow, Tyne & Wear, NE32 3HG DELTA ONE SECURITY SERVICES LTD Tel: Fax: PART 1 Full Name of Applicant:. Position Applied For:. Address: Previous Address:... Tel No:... How Long at this Address:.. Date of Birth: Place of Birth:.... Contact No:. How Long at Previous Address:... Married/Single/Divorced/Separated/Widowed Nationality National Insurance Number /./.././. PART 2 Have you ever been convicted of any criminal offence?......yes/no If YES please give full details Have you any court cases pending?... YES/NO If YES please give full details Have you any outstanding County Court Judgements against you YES/NO If YES please give full details Signed:.Date:.. Disclosure will be requested in the event of the individual being offered the position. WORD\C:\QUALITY SYSTEM\PROCEDURES\SECTION 03\\5\22\04\08 Page 1 of 7

2 PART 3 PREVIOUS WORK EXPERIENCE Please state, where possible, exact dates of previous employment. We require that all our employees be fully vetted due to the sensitive and confidential nature of security work. Failure to disclose any relevant information or to knowingly tender false information in order to gain employment will result in instant dismissal and may subsequently lead to criminal charges being brought. If the history of your employment detailed below does not cover a full 10 years please continue on a separate piece of paper. Name of employer and Contact Name for The purpose of obtaining a Reference Address & Telephone Number Your position with the company Your full dates of employment Your reasons for leaving this job Previous Employment Questionnaire Date Sent Date of Return Personal Referees In addition we require details of two personal referees who have known you and are aware of your whereabouts for the last five years. These may not include relatives or previous employers. 1. Name Telephone No.: Address: 2. Name Telephone No.: Address: Authority to offer /Decision not to offer provisional employment(delete appropriate): Authorised by: Date: WORD\C:\QUALITY SYSTEM\PROCEDURES\SECTION 03\\5\22\04\08 Page 2 of 7

3 PART 4 MEDICAL AND DESCRIPTIVE QUESTIONNAIRE Next of Kin (or person to be informed in the event of an emergency) Name: Relationship:. Address:......Tel No: MEDICAL QUESTIONNAIRE PLEASE COMPLETE THE ATTACHED QUESTIONNAIRE AT THE BACK OF THIS APPLICATION PHYSICAL DESCRIPTION Height:...Weight:. Eyes:.. Collar Size:...Waist:...Chest:. Inside Leg:.Marks/Scars/Tattoos etc. PART 5 NUMERACY AND LITERACY Please indicate which you think is the correct spelling of the following words:- 1. A) nessecary 2. A) elephant 3. A) susspissus B) necessary B) ellefunt B) sucpicious C) necesery C) ellephant C) suspicious 4. A) scientific 5. A) garding 6. A) furtuvly B) scientiphic B) gaurding B) furtively C) sceintific C) guarding C) furtiveley Please enter the answers to the following simple arithmetic problems in the spaces provided: x 7 = = 7. (18 + 7) x 4 = x 11 = 5. (23 8) x 3 = 8. (13 + 9) 1 = x 8 = 6. ( ) x 4 = PART 6 APPLICANTS DECLARATION I hereby declare that the information given by me in the above application for employment is correct to the best of my knowledge and belief. I also understand that I shall render myself liable to prosecution and/or dismissal if I have stated anything in it which I know to be false or do not believe to be true. Name: (Please Print) Signed:..Date:. WORD\C:\QUALITY SYSTEM\PROCEDURES\SECTION 03\\5\22\04\08 Page 3 of 7

4 MEDICAL QUESTIONNAIRE (Strictly Private & Confidential) What is your weekly consumption of alcohol? What is your daily consumption of cigarettes If you have stopped smoking, for how long? Are you on any Medication (if so please state) Should you answer YES to any of the following questions you may be requested for information from your GP or to attend a medical examination to determine your fitness for the post for which you have applied. Do you now or have you in the past, suffered from any of the following complaints? a) Any disorder of the lungs, e.g. bronchitis, pneumonia. YES/NO b) Heart condition, e.g. myocardial infarction, high blood pressure YES/NO c) Arthritis or work related upper limb disorders or any back problem YES/NO d) Diabetes or thyroid disorder YES/NO e) Any neurological disorder including Multiple Sclerosis, stroke etc. YES/NO f) Any form of mental illness, including stress YES/NO g) Cancer / leukaemia YES/NO h) Diseases of the vital organs, (stomach, bowel, liver etc.) YES/NO i) Any communicable diseases, e.g. TB, AIDS, Hepatitis A or B etc. YES/NO j) Eye disorders YES/NO k) Ear disorders YES/NO l) Dermatitis or other skin disorders YES/NO m) Allergies YES/NO n) Other disorder or disease not mentioned above YES/NO Medical Declaration I certify that the above information is correct to the best of my knowledge and belief. Signature: Date: Print Name (BLOCK CAPITALS): WORD\C:\QUALITY SYSTEM\PROCEDURES\SECTION 03\\5\22\04\08 Page 4 of 7

5 NOTES ON FIRST INTERVIEW Interview Criteria Appearance Build Experience Flexibility Attitude Qualifications Driving Licence General Comments INTERVIEWED BY: DATE: NOTES ON SUBSEQUENT INTERVIEW INTERVIEWED BY: DATE: START: YES/NO NUMBER: START DATE: THREE MONTHS PROBATIONARY ASESSMENT INTERVIEWED BY: DATE: CONTRACT ISSUED: YES/NO WORD\C:\QUALITY SYSTEM\PROCEDURES\SECTION 03\\5\22\04\08 Page 5 of 7

6 WORKING TIME REGULATIONS As from the 1 st October 1998 the Working Time Regulations mean that the company cannot employ anyone for more than 48 hours (including overtime) per week unless each employee agrees to work the extra hours. If you wish to be considered for work in excess of 48 hours in accordance with your existing terms and conditions of employment, will you please complete and sign below. If you do not wish to be considered for work in excess of the 48 hours, please leave blank. In signing below you are signifying your agreement to:- 1. Work reasonable hours extra hours as required by the company in accordance with your existing terms and conditions of employment. The period of any such extra hours will be reasonable, but may result in you working more than 48 hours in any one week. Your agreement in this respect does not alter your existing terms and conditions of employment. Your terms and conditions of employment will not change at all. 2. If you decide to terminate this agreement you may only do so upon providing the company with 3 months written notice. I agree to the terms above:- Name: Signed: Date: WORD\C:\QUALITY SYSTEM\PROCEDURES\SECTION 03\\5\22\04\08 Page 6 of 7

7 SECURITY SCREENING AUTHORISATION EMPLOYMENT VERIFICATION Please read this carefully before signing this application form. I understand that employment within the Company is subject to satisfactory references and security screening in accordance with BS I undertake to cooperate with the Company in providing any additional information required to meet these criteria; I authorize the Company and/or its nominated agent to approach previous employers, schools/colleges, character referees or Government Agencies to verify that the information I have provided is correct. I authorise the Company to make a consumer information search with a credit reference agency, which will keep a record of that search and may share that information with other credit reference agencies. I understand that some of the information I have provided in this application will be held on a computer and some or all will be held in manual records. I consent to the Company s reasonable processing of any sensitive personal information obtained for the purposes of establishing my medical condition and future fitness to perform my duties. I accept that I may be required to undergo a medical examination where requested by the Company. Subject to the Access to Medical Records Act 1988, I consent to the results of such examinations to be given to the Company. I understand and agree that if so required I will make a Statutory Declaration in accordance with the provisions of the Statutory Declarations Act 1835, in confirmation of previous employment or unemployment. I hereby certify that, to the best of my knowledge, the details I have given in this application form are complete and correct. I understand that any false statement or omission to the Company or its representatives may render me liable to dismissal without notice. SIGNATURE: PRINT NAME: DATE: WORD\C:\QUALITY SYSTEM\PROCEDURES\SECTION 03\\5\22\04\08 Page 7 of 7

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