Application form | Fusion Staff Agency

1. Personal details

Title: First name: Last name: Email: Phone: Address: Postcode: Marital status: NI number: Date of birth: Do you have any unspent criminal convictions?

Yes

No

Roles with children or vulnerable adults may require disclosure of all convictions under Rehabilitation of Offenders exemptions.

Please give details of unspent convictions:

Would you pass a DBS check?

Yes

No

Are you legally entitled to work in the UK?

Yes

No

2. Work preferences

Sector interest: Employment preference: Role you are applying for: Experience summary:

Are you happy to work night shifts?

Yes

No

Are you happy to work weekends?

Yes

No

3. Health & safety

Tick any that apply. This is special category data and needs your consent below.

Are you currently taking any medicines or receiving prescribed treatment?

Yes

No

Medicines details:

Do you have any other medical conditions that could affect your ability to work?

Yes

No

Other medical details:

4. Night-shift questionnaire

Diabetes:

Yes

No

Heart or circulatory disorders:

Yes

No

Any condition which causes difficulties sleeping:

Yes

No

Chronic chest disorders (especially with night-time symptoms):

Yes

No

Medical condition requiring medication to a strict timetable:

Yes

No

Any other health factors that may affect fitness at work:

Yes

No

I confirm the night-shift answers are true and I will report any changes.

5. Documents

Allowed file types: PDF, Word (.doc/.docx), JPG, PNG, HEIC or WebP. Each file must be 10 MB or smaller (30 MB in total).

CV (required): Passport or photo ID: Right to work document:

6. Working Time Directive, emergency contact & consent

Working Time Directive (48-hour week) opt-out

The Working Time Regulations limit average weekly hours to 48 over 17 weeks unless you opt out in writing. You may withdraw with 3 months' written notice.

I agree that the 48-hour average working week limit shall not apply to me (WTD opt-out). Wtd print name: Wtd signed at: Emergency contact name: Emergency contact relationship: Emergency contact phone:

Privacy notice

I consent to processing of my application data (Privacy notice). I consent to processing of my health information for placement/H&S. I declare the information is true and complete.

Candidate application

1. Personal details

2. Work preferences

3. Health & safety

4. Night-shift questionnaire

5. Documents

6. Working Time Directive, emergency contact & consent