Application Form - MPA Recruitment

Application Form
MPA Recruitment offers a free and confidential service to all our candidates
1. Personal Details
Title: Mr / Mrs / Miss / Ms /
Contact Telephone Number:
Mobile Number:
Email Address:
Town / City:
Date of Birth:
National Insurance Number / PPS Number:
Driving Licence:
Number of Sick Days in Last 12 Months:
Access to Car:
Type Of Work Sought:
2. Other Details
Type of work you are looking for?
What shifts are you interested in working? Please tick:
Permanent F/T □
Permanent P/T □
Day Shift □
Night Shift □
Temporary F/T □
Temporary P/T □
Weekdays □
Weekends □
Morning Shift □
Evening Shift □
Date(s) available for work:
Preferred Annual Salary for Permanent Employment:
Preferred Rate of Pay per hour for Temp Work:
Locations willing to work in / preferred:
3. Bank Details
Name on Account:
Sort Code:
Bank / Building Society Name:
Account Number:
Branch Address:
Building Society Ref:
4. References
Full Names:
Full Names:
Full Address:
Full Address:
Telephone Number:
Telephone Number:
5. Education / Qualifications
School / College / University / Other
Date Completed:
Other Qualifications particular to your experience / post you are looking for?
6. Work History
Previous / Current Employer:
Position Held:
Salary / Rate of Pay:
Dates of Employment (from / to):
Reason for leaving:
Describe the work undertaken:
Previous / Current Employer:
Position Held:
Salary / Rate of Pay:
Dates of Employment (from / to):
Reason for leaving:
Describe the work undertaken:
Previous / Current Employer:
Position Held:
Salary / Rate of Pay:
Dates of Employment (from / to):
Reason for leaving:
Describe the work undertaken:
Rehabilitation of Offenders Act
Do you have any unspent criminal convictions?
If yes, please list:
Yes □
No □
Name: ____________________________
Job Title: _________________________________________________
Contact No: _______________________________________________
(If YES you must include
details, if date unknown please
Have you ever been treated at a hospital for a serious illness or surgery?
How much time have you lost from work due to illness in the last five years?
Are you registered disabled?
Were you ever diagnosed as dyslexic, dyspraxic or any related conditions?
Were you ever diagnosed with aspergers or any related conditions?
Have you ever required adjustments to help you undertake school or work tasks?
Has anyone in your family or household had tuberculosis?
Have you ever had Tuberculosis?
Have you ever been tested for HIV?
Have you ever lived abroad?
Have you ever coughed up blood or had a persistent cough for more than 3 weeks
in the last year?
Have you had unexplained weight loss in the last year?
Have you had unexplained fever, high temperature and/or night sweats?
Do you smoke? How many per day?
Do you drink alcohol? How many units per week?
Are you receiving Medicines or prescriptions from your Doctor?
Do you have any conditions other than those listed above which could
affect how you carry out your assignment?
Do you have any conditions which would make it difficult to undertake night work?
Have you ever suffered from any of the following
Heart / Circulatory Illness / Hypertension
Asthma / Hayfever
Bronchitis / Pneumonia / Pleurisy
Epilepsy / Frequent Fainting Attacks
Severe / Frequent / Prolonged Headaches or Migraines
Psychiatric Illness / Anxiety / Depression
Dermatitis / Psoriasis / Eczema
Allergies to rubber / latex or any drugs
Back Injury / Back Pains
Recurrent Infections (e.g. sore throats / ear Infections)
Hepatitis / Jaundice
Chronic or recurrent diarrhoea / colitis
Problems with your hands, arms, legs or feet which effect movement or normal use
Any illness or disease that makes you more vulnerable to infection
(If YES you must include
details, if date unknown please
Have you had any of the following
(If YES you must include
details, if date unknown please
Chicken Pox (Varicella)
German Measles (Rubella)
Food Poisoning
Have you ever suffered from any of the following
(If YES you must include
details, if date unknown please
Tuberculosis (BCG)
Mumps, Measles and Rubella (MMR)
Hepatitis A
Hepatitis B
Hepatitis C
Swine Flu
I declare that the forgoing statements are true and complete to the best of my knowledge. I am
aware that I will be held responsible for the accuracy of this declaration and that if any answer is
found to be false within my knowledge or any relevant fact has been wilfully suppressed I will be
liable for dismissal.
Signature: ___________________________________
18 Great James Street
028 71360070
13 Sedan Avenue
028 82242595
Date: _____________________
29-33 Montgomery Street
028 95211111
Email: [email protected]
Recruitment of Permanent and Temporary Staff
Co. Registration No. NI40246
17 Stone Row
028 70357035
Contract for Services for Temporary Workers
Between MPA Recruitment Ltd, acting as an Employment Business and herein after
referred to as MPA.
These terms constitute a contract for services between MPA and the temporary
worker and they govern all Assignments undertaken by the temporary worker.
However no contract shall exist between
MPA and the temporary worker between Assignments.
For the avoidance of doubt, these Terms shall not give rise to a contract of
employment between MPA and the temporary worker. The temporary worker is
engaged as a self-employed worker although MPA as
a_______________________________________________________________and is
required to make "statutory deductions from the temporary worker remuneration in
accordance with clause 4.
No Changes will be made to these Terms, unless such changes are agreed with the
Temporary Worker, set out in writing and a copy given to the temporary worker.
MPA agrees to offer to the temporary worker opportunities to work where there is a
suitable Assignment with a hirer, (hereinafter called the Client) requiring such a
MPA reserves the right to offer any Assignment to such temporary workers as it may
elect where that Assignment is open to several temporary workers.
The Temporary Worker acknowledges that the nature of temporary work means that
there may be periods when no suitable work is available, the suitability of the work to
be offered will be determined solely by the Employment Business, MPA shall incur no
liability to the temporary worker should it fail to offer opportunities to work.
MPA shall pay to the temporary worker remuneration calculated at the actual hourly
rate notified on a per Assignment basis for each hour worked during an Assignment
to be paid weekly in arrears, subject to deductions in respect of PAYE pursuant to
sections 44-47 of the Income Tax
(Earning & Pensions) Act 2003 and Class 1 National Insurance Contributions and any
other deduction which MPA may be required by law to make. The hourly rate will be
no less than the minimum wage.
The temporary worker is under no obligation to accept any offer of an Assignment,
but if he/she does so, he/she shall at all times when services are due to a Client
comply with the following conditions:
Not to engage in any conduct detrimental to the interests of MPA.
To be present during the times or for the total number of hours during each day
and/or weeks as may be agreed.
To take all reasonable steps to safeguard his/her own safety and the safety of any
other person who may be affected by his/her actions at work.
To comply with all disciplinary rules or obligations in force at the premises where
services are performed to the extent that they are reasonably applicable.
To comply with all reasonable instructions and requests within the scope of the
agreed services made either by MPA or the Client.
At the same time as an Assignment is offered to the temporary worker, MPA shall
inform the temporary worker of the identity of the Client and, if applicable, the
nature of their business; the date the work is to commence and the duration or likely
duration of the work; the type of work, location and hours during which the
temporary worker would be required to work; the rate of remuneration that will be
paid and any expenses payable by or to the temporary worker; and any risks to health
and safety known to the Client in relation to the Assignment and the steps the Client
has taken to prevent or control such risks. In addition, MPA shall inform the
temporary worker what experience, training, qualifications and authorisation are
required either by law or a professional body and that the Client deems necessary to
work in the assignment. This information will be given to the temporary worker in written or
electronic form no more than 3 days after being offered the assignment.
10. Assignment (each Assignment where there has been a break of 6 weeks since the
end of the previous Assignment shall be considered a first Assignment) or 8 weeks
from the day after the last day that the temporary worker worked on the Assignment,
the client wishes to employ the temporary worker direct or through another
employment business the temporary worker acknowledges that MPA will be entitled
either to charge the client a fee or agree an extended period of hire, at the end of
which the temporary worker may be engaged directly by the Client or through
another employment business without further charge to the client. This also applies
where the client introduces the temporary worker to a 3rd party who subsequently
engages the temporary worker within the relevant period.
At the end of each week of an Assignment (or at the end of an Assignment where it
is for a period of less than one week), the temporary worker shall deliver to MPA a
timesheet duly completed to indicate the
hours worked during the preceding week signed by an authorised representative.
12. Subject to clause 8.3 MPA shall pay the temporary worker for all hours worked
regardless of whether MPA has received payment from the Client for those hours.
13. It is the temporary workers obligation to complete the timesheet and get an
appropriate authorised signature – failure to do so may result in delayed payment.
The temporary worker will be paid weekly, one week in arrears.
There is no obligation by MPA to provide or the temporary worker to serve, any
nominal number of hours in any day or week. The hours of work agreed for each
Assignment will be stated on the contract for services. Failure to attend or leaving
an Assignment for any reason without prior notification for any period will result in
the automatic termination of the temporary workers contract for services.
There is no notice required for a) the temporary worker to terminate the employment
and b) MPA to terminate the temporary workers employment. However, MPA will
endeavour to give the temporary worker at least one days notice and would
appreciate if the temporary worker would return this gesture.
MPA and the temporary worker agree that the nature of temporary work is such
that there may be periods between Assignments when no work is available.
MPA may instruct the temporary worker to end an Assignment with a Client at
any time.
If the temporary worker is ill or likely to be late, he/she must inform the branch by
8.30am. If he/she wishes to end an Assignment or needs to take time off, the
branch must be contacted at least a week in advance.
If the temporary worker wishes to work more than 48 hours in a week, he/she is
legally obliged to sign an 'opt-out' form. This document can be obtained from and
must be retained at his/her local MPA branch. If you do not sign an Opt Out form,
calculating the average weekly hours will be taken over a 17 week period and will
start from the start date of the assignment.
All temporary workers are entitled to 28 days annual leave. This includes 4
nominated bank holidays. To claim this holiday pay the temporary worker must give
1 week notice to his/her MPA branch. This money is to be paid to cover time away
from work for the purpose of annual leave and must not be claimed by the
temporary worker or paid out by MPA for any other purposes. When a temporary
worker leaves MPA and claims their P45, holiday pay will be paid into the temporary
worker's nominated Bank/building society account on the day that the P45 is issued.
MPA temporary workers are entitled to all benefits associated with the temporary
worker benefits, unless stated on their contract for services, after the relevant
qualifying periods.
These Conditions of Work are governed by English law and the parties agree to
submit to exclusive jurisdiction of the English Court
10. If, before the first Assignment or within the relevant period which is either; during the
course of an Assignment, 14 weeks from the start of the first
By signing this contract you also accept the conditions of work as stated above.
Signature of Temporary Worker: _____________________________________
18 Great James Street
028 71360070
13 Sedan Avenue
028 82242595
Date: ________________
29-33 Montgomery Street
028 95211111
Email: [email protected]
Recruitment of Permanent and Temporary Staff
Co. Registration No. NI40246
Opt out Signed: Yes 
17 Stone Row
028 70357035
No 
Opt- Out of a 48 Hour Working Week Agreement
The Regulations say that on average you should not be asked to work more than 48 hours in each
week taken over a 17 week period.
By signing this Opt-Out Agreement you will give yourself the power to decide how many hours per
week you want to work. It gives you the right to plan your working week however you may wish.
You are under no obligation to sign this form
The Opt-Out Agreement is made under the provisions of the Working Time Directive (WTD) 1998
and as such forms part of your Contract of Employment with MPA Recruitment.
The WTD Regulations provide that the worker shall not work in excess of a 48 hour week
averages over 17 weeks unless they have agreed in advanced to do so.
With effect from the 17th December1999 workers who sign an individual 48 Hour Opt-Out
Agreement need not have their working hours recorded for monitoring purposes.
Any worker that wishes to withdraw their Agreement to an existing Opt-Out may do so after
giving appropriate notice to their employer.
I hereby agree to Opt-Out of the 48 Hour Agreement to an existing as specified in the WTD (1998).
(Please Print)
18 Great James Street
028 71360070
13 Sedan Avenue
028 82242595
29-33 Montgomery Street
028 95211111
Email: [email protected]
Recruitment of Permanent and Temporary Staff
Co. Registration No. NI40246
17 Stone Row
028 70357035
Equal Opportunities Questionnaire
Type of work sought: _________________________
Date: ____________
For Monitoring Purposes only
MPA Recruitment monitors the applications it receives for jobs in order to ensure that its recruitment practices promote
equality of opportunity. This information will be treated in the strictest confidence and protected from misuse, and will
not form part of your application. It will be used only for the purposes of monitoring our equal opportunity employment
To demonstrate our commitment to equality of opportunity in employment we need to monitor the community
background of our applicants and employees, as required by the Fair Employment and Treatment (NI) Order 1998.
Regardless of whether we practice religion, most of us in Northern Ireland are seen as either Catholic or Protestant.
We therefore ask you to indicate your community background by ticking the appropriate box below.
I am a member of the Protestant Community
Roman Catholic Community
If you do not complete this questionnaire, we are encouraged to use the 'residuary' method, which means that we
can make a determination on the basis of personal information on file.
It is a criminal offence under the legislation for a person to 'give false information …in connection with the
preparation of the monitoring return'.
Please indicate your gender by ticking the appropriate box below:
Please indicate your marital status by ticking the appropriate box below:
Under the Disability Discrimination Act 1995 a person is considered to have a disability if he/she has a physical or
mental impairment which has a substantial and long-term effect on his/her ability to carry out normal day to day
Do you consider that you meet this definition of disability?
If YES please state the nature, Of or effects of your disability ________________________________________
Please describe your ethnic origin by ticking the appropriate box below:
Irish Traveller
Mixed Ethnic Group
Nationality (please specify)___________________