I hereby give my consent to Direct Recruitment (Midlands) Ltd to process the following information about me:

PERSONAL DATA:                                                                                                                                                                                             

* Name (first and last)

* Date of Birth (DOB)                                                           

* Contact details, including; telephone number (includes mobile number), email and postal addresses.           

* National Insurance Number

* Bank Details 

* Payroll details

(please note this list may not be exhaustive) 

SENSITIVE PERSONAL DATA:

* Passport ID

* Drivers Licence

* Country ID

* Health Information (such as sick notes) 

(please note this list may not be exhaustive)

I PROVIDE THE COMPANY WITH MY CONSENT TO PROCESS MY PERSONAL DATA INFORMATION FOR THE FOLLOWING PURPOSES:

* Being included on a computerised database and to its use in order to secure me with employment/temporary assignments/contracts;

* For the processing of data on a computerised database/system in order to provide payroll and employment services

* To take up references and give its clients relevant information relating to my employment details or this registration, for the purposes of ensuring suitability for working assignments involving cash or valuables including goods, stock or equipment;

* My CV and other personal data being transferred to clients via electronic mail, text message or verbally and I understand the risk of my CV being unintentionally altered during this process;

* To process/transfer my personal data with their third-party companies in order to provide payroll and employment services and the passing of information to certain third parties to present or detect crime, to protect funds or in any other way permitted or required by law.

* If your application is unsuccessful, Direct Recruitment (Midlands) Limited may keep your personal data on file in case there are future employment opportunities for which you may be suited. We will ask for your consent before it keeps your data for this purpose and you are free to withdraw your consent at any time.

* Dormant personal data files will automatically be destroyed after 12 months of registration.

I understand that I can request to have access to my data at any point, that I can request to update my data and I can request to withdraw my consent for Direct Recruitment (Midlands) Ltd to process my data. However Direct Recruitment (Midlands) Ltd may continue to process my personal data where they have a legal obligation to do so.

If, during the course of a temporary assignment, the Client wishes to employ me direct, I acknowledge that Direct Recruitment (Midlands) Ltd will be entitled either to charge the Client an Introduction Transfer Fee, or to agree an extension of the hiring period with the Client (after which I may be employed by the Client without further charge being applicable to the Client).

I hereby declare that to the best of my knowledge the information contained in this form is true and accurate. I understand that any false declaration may render me liable to dismissal. 

Please sign below to provide consent.

This form is issued to help identify any health problems or disability that may be relevant to your application. Your must declare all illnesses that you have suffered. Please answer all questions, inputting N/A if not applicable.

Do you have any problems with your vision or your eyes, other than the simple need to wear glasses?

If you wear glasses/lenses, when was your prescription last checked?

If you do not wear glasses/lenses, has an optician ever recommended that you should use glasses or lenses for work?

Have you ever experienced any of the following? If yes please detail below including dates.

• Epilepsy
• A blackout or impairment of consciousness
• A stroke or mini-stroke
• Sudden and troublesome dizziness or vertigo
• Serious head injury in the past
• Any form of tumour in the brain
• Surgery on the brain
• Parkinson's Disease or Multiple Sclerosis
• Dementia

Have you ever experienced any of the following? If yes, please detail below.

• Have you had any mental health problems over the past 6 months for which you have needed treatment from a doctor?
• Have you ever suffered from a Psychotic illness such as schizophrenia or manic depression?
• Are you currently on any medication or any other treatment for a mental health problem such as anxiety or depression?
• Have you regularly misused drugs, alcohol or prescribed medicines at any time in the last 12 months?
• Have you ever been addicted to any drugs, alcohol or prescribed medicines at any point over the last 3 years? 

Have you ever experienced any of the following? If yes, please detail below including dates

• Angina
• Heart failure or Heart attack
• Heart Surgery or transplant
• Blocked arteries
• Irregular Heartbeat
• Diseases affecting your arteries or circulation
• Aortic Aneurysm
• Heart murmur
• Embolism (blood clot)
• any other heart issue not listed

Do you suffer from high blood pressure and are you on any treatment for this?

Have you ever experienced any of the following? If yes, please detail below including dates

• Diabetes
• Spine, neck, limb or joint issues that affect your mobility or ability to work
• Cancer
• Hearing problems
• Liver or Kidney Disease
• Sleep Apnoea Syndrome

I certify that the statements I have made above are correct and complete to the best of my knowledge and belief. I understand that the medical assessment of my fitness to work will be based on the information I have provided about my health above. I accept full responsibility for the accuracy and completeness of the information I provide about my health and fitness, including my responsibility for any consequences of my providing inaccurate or incomplete information.

Drivers only: I understand that any work will be offered on the basis of the health information I have provided above, and will therefore be subject to my health not changing materially between now and my my next medical review or licence renewal. I accept that it is my responsibility to notify the DVLA, if my health changes, particularly if any change would lead to my having to give a different answer to any of the questions above. I am aware of and accept my full responsibility for any consequences of my failing to notify such a change in my health status.

We are asking you to complete this form in relation to job roles which are not exempt from the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (2013 and 2020).  For this reason, you are only required to disclose information about unspent convictions. You are not required to disclose spent convictions on this form. This information will be treated in the strictest of confidence and only taken into account where the offence is relevant 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. However a criminal record will not necessarily be a bar to obtaining a position. 

Option 1: You can disclose your criminal record on a separate sheet and forward this to Direct Recruitment (Midlands) Ltd in an envelope marked Confidential. Please answer below if this is your preferred choice.

Option 2: Please provide details in the box below.

I declare that the information provided on this form is correct. I understand that the declaration of a criminal record will not necessarily prevent me from being offered a role at Direct Recruitment (MIdlands) Ltd