Position Applied For

- SELECT POSITION - Experienced Coach Drivers Part-Time Minibus Drivers

Full Name*

Address*

Phone Number*

Mobile

Email*

Qualifications*

Date of passing P.C.V. test

Previous experience*

Licence number*

Date of expiry

Driver CPC qualification

Yes      No

If Yes, expiry date

Do you have a current CRB/DBS

Yes      No

If yes, what is the date of the Disclosure/Certificate

If yes, which organisation/company carried out the check

List below any motoring convictions, past or pending during the past 5 years.

Date of conviction

Offence code

Date of offence

Fine £

Disqual period

1.

2.

3.

List below any criminal convictions not covered by the rehabilitation of offenders act, 1974

Offence

Court

Date of conviction

Penalty

1.

2.

3.

Details of previous employment & periods of unemployment for last 5 years - Current

Employers Name & Address

From

To

Reason for leaving

1.

2.

3.

Is there any period between jobs (or long absence from work whilst in employment) due to ill health? Give details

Do you have any holiday commitments? If so, give details

From

To

Medical Information

Height (ft.ins)

Weight (stone.lbs)

Age

Date of birth

Are you disabled?*

Yes      No

If yes, please specify your Disabled Registered Number?

Date of expiry

Nature of disability

Have you suffered from any of the following health complaints?

Dermatitis/Eczema
Skin Cancer
Ulcers (e.g. Gastric, Duodenal)
Deafness
Ear Infection
Sinusitis
Chest trouble
Bronchitis
Asthma
T.B.
Rheumatic Fever
Heart Trouble
Sclerosis
Diabetes
Rheumatism
Arthritis
Fibrosis
Fits (e.g Epiletic)
Fainting Attacks/Giddiness
Back Trouble
Migraine
Nervous Breakdown
Mental Disorders
None

If you have ticked any of the above, please give dates and brief details (e.g. isolated or recurring complaint)

Do you wear spectacles/contact lenses at work?*

Yes      No

If Yes, please specify

Have you had any serious accidents at work?*

Yes      No

If Yes, please specify

Are you currently receiving any medical treatment?*

Yes      No

If Yes, please specify

Family GP (Name)

Practice Name

Practice Address

Do you give your consent for your G.P. to supply details of you relevant medical history?

Yes      No

Would you be willing to have a medical examination if deemed necessary?

Yes      No

Vocational Qualifications and Other Skills

Please give details of any other skills/qualifications (E.g. Fork Lift truck accredited licence, first aid certificate etc)

Further Information

Please use this space for additional information and/or outline the reasons you would like to work for ASD Transport. You should also use this space to give any relevant information which may have a bearing on your suitability to be a PCV driver. You may like to include details of any experience of dealing with members of the public, handling cash, hobbies and interests, including memberships of clubs and societies and any personal achievemnets you are proud of.

How did you hear about this vacancy?

References

Referee 1

Name of Referee

Title/Position

Company Name

Address

Tel

Fax

Referee 2

Name of Referee

Title/Position

Company Name

Address

Tel

Fax

At this stage do we have permission to contact your referees?*

Yes      No

If No, please indicate when it would be acceptable (eg, on provisional offer of job)

I declare that the information provided on this application form is correct and understand that if any adverse facts come to the notice of the company then there may be grounds for dismissal

I Agree