| Application Form |
Personal Details: Please paste a copy of your recent passport photograph below
Surname: Mr/Mrs/Miss/Ms
Forenames:
Address:
PHOTO
Postcode:
Contact Mobile:
Contact home: Sentinel No:
Date of Birth: National Insurance No:
Ethnic Origin: Marital Status: Married / Single / Divorced / Other (circle one)
Details of next of Kin: Who could be contacted in case of emergency
Name: Relationship:
Address:
.................
................................
................................
.. Tel No:
Do you have any disabilities? Yes / No (circle one
If any disability, please provide details:
.......................................
.......................................
Are you physically fit? Yes / No (circle one) If no give details:
.......................................
Do you wear glasses or contact lenses for normal vision? Yes / No (circle one) If yes give details:
.......................................
Do you hold a full current driving licence? Yes / No (circle one) If yes state date of issue:
Supply a copy.
State details of any endorsements/impending prosecutions If any give details:
.......................................
Have you ever been convicted of a criminal offence? (other than a spent conviction under the rehabilitation of offenders Act 1974) Yes / No (circle one) If yes give details:
.......................................
.......................................
Employment History: (past 3 years)
Date:
From: To: Name and Address of Employer Position Reason for leaving
Wage:£
Wage:£
Wage:£
Wage:£
Wage:£
Have you ever been dismissed for railway related transgressions in the past 3 years? Yes / No (circle one)
If yes, provide details
..............................................................................................
................................................................................................................................
Applicants signature: Date:
Please supply two references who the company can contact.
Reference 1:
Name:
Contact Details:
.
Reference 2
Name:
Contact Details:
..
.
.
Equal Opportunities:
This section is being used to monitor the effectiveness of our equal opportunities policy and for no other reason. May we therefore ask you to please complete this section accurately? Information given will be treated in strict confidence. Please tick appropriate boxes.
Sex Male Female
I would describe my ethnic origin as:
White Pakistani
Black Caribbean Bangladeshi
Black African Chinese
Black other Indian
Other, please specify:
..............................................
CANDIDATE: Please do not write below this line.
This section to be completed by M & M Rail Services Manager.
State how you verified this candidates details.
Delete as appropriate:
1. Postal letter to candidates home requiring reply.
2. Contact of previous employer.
3. NCCA contacted.
4. Candidate known to M & M Rail Services Manager.
5. Passport checked.
6. Relative of current M & M Rail Services employee.
7. Other - please state below.
..............................................................................................................................................
Name: Signature: Date:
NETWORKRAIL
Safety and Standards Directorate
Medical Self Assessment for Access on or Near the Line
Name:
......
Work for which to be employed:
.........................
It is important to be accurate with your answer to this questionnaire, although trivial matters should be ignored. When you declare NO, you are accepting a degree of responsibility for your safety. If in any doubt seek medical advice and tell your employer.
Please study this list and sign it at the bottom. Your employer (or person responsible for your work on the railway) should also sign and retain this form.
NO YES
Do you have Diabetes needing Insulin
Do you suffer from Epilepsy or Fits
Have you ever had blackouts, recurrent dizziness or any
Condition, which may cause sudden collapse or incapacity
Do you get discomfort or pain in the chest or shortness of
Breath when exercising.
Do you have difficulty in moving rapidly over short distances
Including on slopes, steps or rough ground.
Would you have difficulty in looking over either shoulder
Do you have any difficulty with your eyesight
Do you have any difficulty hearing normal conversation
Are you taking any medication that is giving you dizziness or
Drowsiness
Have you used drugs of abuse within the last 12 months
Sign: Name: Date:
..
Notice to Employer: If the applicant declares YES a medical assessment must be carried out before he/she is permitted to work on or near the line
Employees Personal Issue Rule Books.
I, the undersigned confirm that I currently hold the documents detailed below.
Publication Issue No & Date
Personal Track Safety Handbook
Rule Book Module GI
Rule Book Module G2
Rule Book Module AC1
Rule Book Module AC2
Rule Book Module T2
Rule Book Module T3
Rule Book Module T4
Rule Book Module T5
Rule Book Module T6
Rule Book Module T7
Rule Book Module T8
Rule Book Module T9
Rule Book Module T11
Rule Book Module T12
Rule Book Module S1
Rule Book Module M5
Rule Book Module SS2
Rule Book Module TW8
Rule Book Module OTP
Rule Book Module OTM
Any other modules detail below:
Employees Name:
Signature:
.
Date:
Please complete this form fully to enable us to make payments into your bank account
BANK/BUILDING SOCIETY ACCOUNT DETAILS FORM
NEW STARTERS
You will be paid directly into your bank account in arrears following acceptance of time sheets.
Employee Name: (Mr/Mrs/Miss/Ms)
...........
Bank/Building Society Details:
Name of Account Holder
.............
Name of Bank/Building Society
.
.........
Bank/Building Society Address
.............
............
............
............
Sort Code
/
/
../
../
./
../
Account Number
../
../
../
../
../
../
../
../
Reference Number
/
../
../
../
../
../
../
../
../
../
../
../
../
../
(Building Society Only)
Signed
................................
Date
................................
|
