Please fill application in full, failure to do so may result in delay of interview

    Your Details




    Date of Birth

    National Insurance Number


    Email Address

    Mobile Number

    Home Number

    Contact Preferences

    Emergency Contact Information

    Emergency Contact

    Relationship to you

    Telephone Number

    Doctor's Name

    Doctor's* Telephone Number

    Doctor's* Surgery & Address


    Name of contact


    Telephone Number

    Dates worked for company

    Other Information

    Do you have your own transport to get to work?

    Driving License

    Do you have any avian pets at home?

    Over 25

    Areas of interest

    Other (specify)

    Applicant Agreement

    1. Equal Opportunities Statement

    PB Recruitment Solutions Ltd (PBRS Ltd) is committed to a policy of equal opportunities for all work seekers.

    • We will review on an ongoing basis all aspects of recruitment to avoid unlawful or undesirable discrimination.

    • We will treat everyone equally irrespective of sex, sexual orientation, gender reassignment, marital or civil partnership status, age, disability, color, race, nationality, ethnic or national origin, religion or belief, political beliefs or membership or non-membership of a Trade Union and we place an obligation upon all staff to respect and act in accordance with the policy.

    • PBRS Ltd shall not discriminate unlawfully when deciding which candidate/temporary worker is submitted for a vacancy or assignment or in any terms of employment or terms of engagement for temporary workers.

    • PBRS Ltd will ensure that each candidate is assessed only in accordance with the candidate’s merits, qualifications and ability to perform the relevant duties required by the vacancy.

    2. Criminal Convictions

    • Certain types of employment and professions are exempt from the Rehabilitation of Offenders Act 1974 and in those cases, particularly where the employment is sought in relation to positions involving working with children or vulnerable adults, details for all criminal convictions must be given.

    • The information given will be treated in the strictest of confidence and only taken into account where, in the reasonable opinion of PB Recruitment Solutions Ltd, the offence is relevant to the post to which you are applying.

    • Failure to declare a conviction may require us to exclude you from our register or terminate an assignment if the offence is not declared but later comes to light.

    Do you have any unspent* criminal convictions?

    If Yes, state convictions and dates

    3. Permission to work in the UK

    Do you have immigration permission to work in the UK?

    In line with “UK Visas and Immigration” guidance on the prevention of illegal working, we will need to verify and take a copy of your original ID documentation as evidence of your right to work in the UK if you are to be engaged by PB Recruitment Solutions Ltd for temporary work.

    4. Health and Disability

    The following questions on health and disability are asked in order to find out your needs in terms of reasonable adjustments to access our recruitment service and to find out your needs in order to perform the job or position sought.

    Do you have any health issues or disability which may make it difficult for you to carry out functions which are essential for the role you seek?

    Do you have any health issues or a disability relevant which may make it difficult for you to carry out functions which are essential for the role you seek?

    5. Data Protection Statement

    • The information that you provide on this form and on any CV given will be used by PB Recruitment Solutions Ltd to provide you work finding services.

    • In providing this service to you, you consent to your personal data being included on a computerised database and consent to us transferring your personal details to our Clients (hirers and potential employers).

    • We may check the information collected with third parties or with other information held by us.

    • We may also use or pass to certain third parties information to prevent or detect crime, to protect public funds, or in other ways permitted or required by law.

    6. Candidate Declaration

    • I hereby confirm that the information given is true and correct.

    • I consent to my personal data and CV being forwarded to potential employers and hirers.

    • I consent to references being requested from my previous workplace (s) and to references being passed onto potential employers and hirers.

    • If, during the course of an assignment, the client (i.e. hiring company) wishes to employ me direct, I acknowledge that PB Recruitment Solutions will be either entitled to charge the Client and introduction fee, or to agree an extension of the hiring period with the Client.

    Your Name

    Medical Questionnaire


    Please provide the following medical information in order for us to assess whether you are able to carry out the requirements of the job, to ensure your personal safety and for us to comply with any statutory requirements. This information will be treated in the strictest confidence and will only be used in compliance with the Data Protection Act 1998.

    Do you now, or have you ever suffered from any of the following? Please select Yes or No in respect of each condition.


    Skin Cancer

    Gastric Ulcers

    Deafness/Ear Infections

    Recurrent Back Pain



    Chest Trouble

    Eye Disorders


    Hay Fever

    Rheumatic Fever

    Heart Problems


    Heart Problems



    Alcohol dependency


    Fits (e.g. epileptic)

    Fainting attacks/giddiness


    Nervous breakdown

    Mental disorders

    Drug dependency

    If the answer is yes to any of these conditions, please give dates and details in the space provided below:

    Do any of your beliefs restrict you from working in any particular job or working environment?

    Would you be prepared to take a drug or alcohol test?
    (This is a requirement of some of our customers)

    Would you be prepared to participate in random searches at the client premises before/after or during your assignment?
    (This is a requirement of some of our customers)

    Do you have any health-related conditions that will require reasonable adjustments to be made to the selection process?

    UK and EC legislation puts the onus on employers to satisfy themselves that no food handler poses a hygiene risk to the product. Please answer the following questions if you will be working with food.

    At present, or in the last seven days, are you suffering from diarrhoea and/or vomiting?

    At present, or in the last seven days, are you suffering from stomach pain, nausea or fever?

    At present, are you suffering from skin infections of the hands, arms or face - e.g. boils, styes, septic fingers or discharge from eye / ear / gums / mouth?

    At present, are you suffering from jaundice?

    Do you suffer from recurring infections of the skin, ear or throat?

    Have you ever had typhoid or paratyphoid fever or are you now known to be a carrier of Salmonella Typhi or Para typhi?

    Are you a carrier of any type of Salmonella?

    In the last 21 days have you had contact with anyone, at home or abroad, who may have been a carrier of any type of salmonella?

    Have you been overseas in the last 6 weeks?

    How many times in the last 5 years have you had more than two consecutive weeks off sick from work?

    How many days have you had off sick in the last two years?

    Please give details of any medical treatment you are currently receiving?

    Please give details of any medication you are taking

    Have you had any serious illness or operation in the last 5 years? Please give details.

    Have you worked in an industry with high noise levels or been exposed to the use of hand held vibratory tools? Please give details and dates.

    Have you ever made a claim for Industrial Disease or injury? Please give details

    GDPR Consent

    I hereby give my consent to the Company to process the following information:

    Personal data

    • Name
    • Date of birth
    • Contact details, including telephone number, email address and postal address
    • Experience, training and qualifications
    • CV
    • National insurance number
    • Identification
    • Salary Information
    • Doctors Details
    • Emergency Contact information

    Sensitive personal data

    • Disability/health condition relevant to the role
    • Criminal conviction
    • Medical information incorporated within the medical questionnaire.

    I consent to the Company processing the above personal data for the following purposes:

    • For the Company to provide me with work-finding services.
    • For the Company to process with or transfer my personal data to their client/s in order to provide me with work-finding services.
    • For the Company to process my data on a computerised database in order to provide me with work-finding services.

    I also consent to the Company processing my personal data with third parties for the purposes of internal audits and investigations carried out on the Company to ensure that the Company is complying with all relevant laws and obligations.

    The consent I give to the Company will last for the time period I am registered with the agency.

    I am aware that I have the right to withdraw my consent at any time by informing the Company that I wish to do so.


    I certify that I have answered the questions in this questionnaire honestly and fully and that I am not otherwise aware of any physical or mental disability, which will or may affect my working capacity. I am aware that any false or incomplete statement may affect my appointment or future employment.

    Your Name

    Note: By clicking 'Submit Application' below, you are digitally signing the contents of this application.