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The Working Time Regulations 1998 provide that a worker shall not work in excess of 48 hours averaged over a 17-week period unless s/he agrees in writing that this limit should not apply. You may change your decision with one week’s notice. Please sign one of the following to state your preference.

I wish to opt out of the Regulations and so I am prepared to work an average of more than 48 hours per week in any 17-week period

I do not wish to opt out of the Regulations as I do not wish to work an average of more than 48 hours per week in any 17-week period

If you wish to work in Great Britain, do you have British residency? (Pre Settled or Settled status)

YES NO

Do you have Frontier Worker visa?

YES NO

Bank / Building Society:

Account Name:

Sort code:

Account number:

If you have an EUR account, please specify the name of the bank:

Do you have any health related condition that will require reasonable adjustments to be made to the selection process?

NO YES

If Yes please give details

At present, or in the last seven days, are you suffering from diarrhoea and/or vomiting?

NO YES

If Yes please give details

At present, or in the last seven days, are you suffering from stomach pain, nausea or fever?

NO YES

If Yes please give details

At present, are you suffering from skin infections of the hands, arms or face e.g. boils, styes, septic fingers or discharge from eye / ear / gums / mouth?

NO YES

If Yes please give details

At present, are you suffering from jaundice?

NO YES

If Yes please give details

Do you suffer from recurring infections of the skin, ear or throat?

NO YES

If Yes please give details

Have you ever had typhoid or paratyphoid fever or are you now known to be a carrier of Salmonella Typhi or Paratyphi?

NO YES

If Yes please give details

Are you a carrier of any type of Salmonella?

NO YES

If Yes please give details

In the last 21 days have you had contact with anyone, at home or abroad, who may have been suffering from typhoid, paratyphoid or COVID-19?

NO YES

If Yes please give details

In the last 2 weeks, have you visited countries / areas with an increased risk of COVID-19 infection?

NO YES

If Yes please give details

Are you or have you been infected with COVID-19 in the last 3 weeks?

NO YES

If Yes please give details

Countries visited in the last 6 weeks:

In order to process your application you must confirm that you have read and agree to the following:

I confirm that I have read and agree to the Privacy Agreement (Privacy Agreement)

I confirm that I have read and agree to the terms and conditions (Terms and conditions)

I confirm that I have read and agree with the mediation contract and the processing of personal data (Mediation contract)

I confirm that all questions on the form have been completed correctly and honestly.