APPLICATION FORM

Agency Name

Title Title *MrMrsMsMissDrSirLordLady

Forenames

Surname

Date of Birth - DD/MM/YYYY

Nationality

National Insurance Number - Please use capital letters and no spaces e.g: AB987654C

Address

Postcode

Contact Phone Number

Email Address

Job Title

Start Date - Please follow this format - 01/01/2022

Bank Name

Account Holders Name

Sort Code - 123456

Account Number - 12345678

Agency Workers Regulations - Have you worked for the end client before? (the company you will work for day to day) Agency Workers Regulations - Have you worked for the end client before? (the company you will work for day to day) Yes No

Name of your next of kin - Full Name

Next of kins Phone Number - Mobile Number

Relation to Next of kin - Parent, Friend, Sibling etc

Starter Declaration - A. This is my first job since 6th April and I have not been receiving taxable Jobseeker’s Allowance, Employment and Support Allowance or taxable Incapacity Benefit or a state or occupational pension. B. This is now my only job, but since last 6th April I have had another job, or have received taxable Jobseeker’s Allowance, Employment and Support Allowance or taxable Incapacity Benefit. I do not receive a state or occupational pension. C. I have another job or receive a state or occupational pension. Starter Declaration - A. This is my first job since 6th April and I have not been receiving taxable Jobseeker’s Allowance, Employment and Support Allowance or taxable Incapacity Benefit or a state or occupational pension. B. This is now my only job, but since last 6th April I have had another job, or have received taxable Jobseeker’s Allowance, Employment and Support Allowance or taxable Incapacity Benefit. I do not receive a state or occupational pension. C. I have another job or receive a state or occupational pension. A B C

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