Your details are already registered with this agency, you will need to contact the agency direct to re-register your details.
1. Please enter your full name
2. Please enter your date of birth
3. Do you have a physical or mental impairment that could be classed as a disability under the Equality Act 2010?

The Equality Act 2010 defines a person with a disability as “A physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities.”  
4. If yes, what facilities/adjustments/equipment might enable you to perform the role? 
5. Have you ever had to give up a previous job for medical reasons?
6. If YES, please provide brief details.
7. Have you been off work continuously for more than a month in the last five years?
8. If YES, please provide details. 
9. Do you regularly take tablets or medicine?
10. If YES, what do you take? Give as much detail as you feel is necessary
11. Has any previous occupation caused you health problems? 
12. If YES, please provide details
13. Are you in receipt of a medical pension or other disability benefit? 
14. If YES, please provide details.
15. Is your eyesight normal (with glasses/contact lenses if worn)?   
16. Is your hearing normal?                       
17. By signing the below

I am willing to undergo a medical examination if required and declare that the information given in this questionnaire is true and complete. I will notify you immediately if any of my answers change on my completed questionnaire. 

Criminal Deceleration

The Rehabilitation of Offenders Act 1974 requires applicants to declare:


  • Unspent convictions and/or unspent conditional cautions


For further information on how long it takes for convictions and conditional cautions to be spent, please refer to https://www.gov.uk/government/publications/new-guidance-on-the-rehabilitation-of-offenders-act-1974 for further guidance. We recognise the contribution that people with criminal records can make as employees and volunteers and welcome applications from them. A person’s criminal record will not, in itself, debar that person from being appointed to this post. Any information given will be treated in the strictest confidence. Suitable applicants will not be refused posts because of offences which are not relevant to, and do not place them at or make them a risk in, the role for which they are applying.

All cases will be examined on an individual basis and will take the following into consideration:

  • Whether the conviction is relevant to the position applied for.
  • The seriousness of any offence revealed.
  • Your age at the time of the offence(s).
  • The length of time since the offence(s) occurred.
  • Whether the applicant has a pattern of offending behaviour.
  • The circumstances surrounding the offence(s), and the explanation(s) provided.
  • Whether your circumstances have changed since the offending behaviour.


It is important that applicants understand that deliberate attempts to conceal the information requested in this form could result in disciplinary proceedings or dismissal. Further advice and guidance on disclosing criminal records can be obtained from https://www.gov.uk/government/publications/new-guidance-on-the-rehabilitation-of-offenders-act-1974.

You will be asked to provide further details for job roles that are exempt from The Rehabilitation of Offenders Act 1974. This may include a further declaration for The Rehabilitation of Offenders Act 1974 and/or a DBS check.

Some examples of exemptions include(this is not an exhaustive list):

  • Jobs which involve working with children
  • Jobs in the legal system
  • Jobs in healthcare
  • Jobs in Accounting
  • Some transport jobs (such as Taxi Drivers)
  • Jobs with animals (such as Vets, and RSPCA workers)
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1. Please provide your full name
2. Please select todays date(this may also be timestamped on submitting the form):
3. Do you have any unspent convictions or conditional cautions?
4. If you have answered 'Yes' please provide details below
5. DECLARATION

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 this role through CB Staffing Solutions Ltd