Your details are already registered with this agency, you will need to contact the agency direct to re-register your details.
1. Have you got any medical conditions that have an effect on your ability to carry out normal day to day activities?
2. Are you eligible to work in the UK? 
3. Do you have any criminal convictions that are unspent?
4. Do you have any impending prosecutions?
I wish to opt out of the 48 working week limit. I understand that I can withdraw my consent by giving Extra Recruitment 1 weeks notice.

I understand that my pay rate may vary from assignment to assignment and that I will be advised of this when I start a new assignment.

I agree to notify Extra Recruitment of any changes to my personal circumstances, such as health problems and driving license indorsements that may affect my ability to work.

I agree that Extra Recruitment may disclose personal details to a client in order to secure work. These disclosures will be limited to name, age, driving license details, work history and CV.

I agree to notify Extra Recruitment at least one hour before the start of any assignment if for any reason I cannot get to the assignment. Failure to do so may result in my dismissal.

For the purpose of the Agency Working Regulations 2010, I have provided Extra Recruitment with a full accurate account of my work history for at least the last six months.

I hereby acknowledge that I have received, read and understood the Terms and conditions of Employment and I agree to be bound by the terms therein.

5. Data Protection and 3rd Parties Date

Protection laws - means the Data Protection Act 2018, the General Data Protection Regulation (EU 2016/679) and any applicable statutory or regulatory provisions in force from time to time relating to the protection and transfer of personal data;

All information you have provided to us in this application pack will be inputted and stored on our central database. We will keep both copies of the data for 3 years following your last assignment with us (if you do not undertake an assignment with us we will keep it for 3 years following the date of registration). We will use your information to carry out periodic licence checks, send payslips/documents (either via email or post) and to pay you for any assignments that you carry out for us. We will pass on your information to 3rd parties on a need-to-know basis, for example if a client wishes to carry out a licence check themselves we will send them your National Insurance Number, Post Code and Date of Birth. If you believe that we are not handling your data securely or correctly you can contact the Information Commissioners Office on 0303 123 1113. At any point you can request to review the information we have on file for you and ask us to delete the information if you wish.

NIGHT WORK If you are asked to work at night (between 11pm and 6 am) you must not work more than 48 hours in any week. In cases where the work is hazardous or strenuous, 8 hours night work in 24 is the absolute maximum you should work. If this is the case, we will tell you. Similarly, if you are going to work at night you will need to undergo a health assessment to make sure that this will not damage your health. We will ask you to complete a simple questionnaire to help assess this. You may then also be required to have a medical examination and the decision as to whether you are suitable for night work will be at our absolute discretion. It is vital that, if the client asks you to perform night work you let us know so that we can comply with the law.

MODERN SLAVERY Are you forced to do work when you don’t want to? Do you have to pay someone money to give you work? Are you forced to live in accommodation against your will? Is someone controlling your identity documents or bank account? Is someone threatening or intimidating you or your family? If you answer YES to any of these questions, tell a trusted manager, worker representative and:

• Report it to the Modern Slavery Helpline on 0800 0121 700 or at https://www.modernslaveryhelpline.org/report.

• Call the Police in an emergency on 999, or 101 if it is not urgent. For more information visit www.stronger2gether.org    

6. Date
7. PLEASE ENTER YOU FULL NAME 
1. Any allergies or sensitivity to certain substances (including sensitivity to antibiotics or other drugs) 
2. Any skin diseases 
3. Heart disease, circulatory disorder or high blood pressure 
4. Asthma or hay fever
5. Fits, blackout or epilepsy 
6. Any back, neck or other muscular complaints, or trouble bending and lifting
7. Exposure to excessive levels of toxic substances, dust or noise 
8. Hearing problems, discharge or infection of the ears  
9. Rupture, varicose veins or foot ailments 
10. Eye disease, injury or significant defect of vision not corrected by spectacles 
11. Diabetes
12. Recurrent sore throats or sinusitis  
13. Bronchitis, pneumonia or tuberculosis 
14. Suffer from or come into contact with anyone suffering from Hepatitis A, Norwalk virus, Salmonella, Typhoid Cholera, Shigella, Paratyphoid, Dysentery, Norovirus, Streptococcus, Staphylococcus, E.coli 
15. Kidney or bladder infection 
16. Receiving injections, pills, tablets or medicines from doctors (other than contraceptives) (Please state below which medication you are taking)  
17. Suffered from skin lesions, open wounds in last 7 days
18. Suffered from any vomiting, diarrhoea or fever in last 7 days 
19. Recently returned from any endemic countries 
20. Do you bite your fingernails? 
21. Any mental health condition, i.e. stress, depression, anxiety/panic attacks  
22. Any condition or disability not included on this form? 
23. Any other condition that has an effect on your ability to carry out normal day to day activities such as mobility; manual dexterity; physical co-ordination; ability to lift, carry or move everyday objects; speech; memory or ability to concentrate? 
24. Any condition which may be affected by night working
25. Any condition which requires medication or meals to a strict timetable
26. Are you able to carry out repetitive lifting from ankle to shoulder height with weights up to 25kg?  
27. Are you able to push & pull objects?  
28. Are you able to load objects onto platforms or other mechanisms?  
29. Are you able to use a pallet truck and move pallets?