date:.. ………………………….

interviewed by:….…………………………

APPLICATION FORM
Please complete all sections of the application form. The form should be completed in black ink or
type. [BLOCK LETTERS]

Office use only

Warhouse operatives
Post applied for:

Punctuality, experience in picking/packing and other warhouse duties,flexibility.

Key skills:

pre-
English language: poor basic intermediate Fluent*
intermediate

1. Personal Details

Surname/Family Name: First Name(s):

Rajchert Przemyslaw KOnrad

Address: Date of Birth:

06.01.1984
20 Progress DR. Caldercruix Title:
MR
Postcode:
ML6 7PP Home Tel No:

National Insurance Number: Mobile No:

SJ 84 53 66 C 07594862652
Immigration Status (for non EU citizens): Email address:
[email protected]

2. Bank Details (Your salary will be paid by BACS only)

 Name & Address of Bank / Building Society: Account Name:
Clydesdale Bank Mr P.Rajchert

Sort Code: Account Number:

82-60-18 60471941

3. Career History

Please provide information about all relevant previous employers, starting with the most recent, along
with information about any significant gaps in your employment history.

Present or Most Recent Employment

Name of Employer: Job Title:

BOOTS Warhouse operative
Address: Current salary:
Sandanded PL 6.50
Pension Scheme:

Benefits:
Postcode:
Start date: 02.2009 Notice period:
End date: 02.2010

Reason for leaving if no longer employed:

Ed of contract

Previous Employment

Employer Position Held Dates Employed Reason for Leaving

(Full name & address)
DHL Scotland Warhouse 06-2008 till 02.2009 End of contract
operative/data
entry clerk

*Continue on separate sheets, if required.*

4. Additional Supporting Information

For all posts, please use the space below to tell us about your skills and experience and how they
satisfy each of the criteria on the job specification. Please continue on separate sheets, if required.

5. Education and Qualifications

Starting with the most recent – (please list those relevant to the post applied for):

Name of Institution Qualification Grade

Comercial economical studies

High school High School finlas

6. Referees
Please provide the contact details of three referees, one of whom should be your current or most
recent employer or line manager. If you have no, or limited previous employment, please provide
referees from your school, college or training scheme or from any voluntary/temporary work. Do not
include family members or friends.

Name: Jonh Short Address:

Job Title: Manager

Telephone No: 07779800301

Email: Postcode:
Please indicate whether a
reference may be obtained
prior to interview:
Yes* / No
Relationship to referee:
My manager

Name: Scot Dickson Address:

Job Title: DHL

Telephone No: 07866367104

Email: Postcode:
Please indicate whether a
reference may be obtained
prior to interview:
Yes* / No
Relationship to referee:
Agency consultant, responible for my employment in DHL

Title: MR Address:

Name: Janusz Drybek

Telephone No: +48606942647

Email: Postcode:
Please indicate whether a
reference may be obtained
prior to interview
Yes* / No
Relationship to referee:
My supervisor in Poland

7. Other personal details

Please see our Guidance for Applicants which provides further details on each of the following
sections and whether further information is required. It also includes the contact details of the
Recruitment Officer to whom information required in this section should be sent.

Accessibility

We want to ensure that all candidates have equal access to our recruitment and selection procedures.
If you have any specific requirements relating to accessibility that may affect your work or ability to
carry out the duties associated with the post, please contact the Recruitment Officer (our contact
details are shown at the bottom of the next page).

Health
Do you have a health condition that may affect your work or ability to carry out the duties associated
with the post that you are applying for? Yes / No*

If “Yes”, please provide some brief details:

Criminal Convictions
Please refer to the Guidance for Applicants. Do you have any criminal convictions which are not
spent? Yes / No*

If you have any spent convictions please refer to the Guidance for Applicants on when these need to
be disclosed:

8. Declaration

I confirm that the information provided above, and in any attachments and supplementary information,
is correct and understand that any false statement could result in my application or appointment being
terminated. I have read Section 7 and the Guidance for Applicants and have forwarded additional
information to the Recruitment Officer where applicable.
(Please type your name below if you are returning the form by email or sign if you are returning it by
post).

Signature: Date:

Rajchert Przemyslaw 11..08.2010

PPE (Personal Protection Equipment)

If Primo Executive Recruitment has to supply you with any personal protection equipment e.g. boots,
high visibility vest or hard hats, Primo Executive Recruitment will deduct the cost of the equipment
from your wage.

Signature: Date:

Rajchert Przemyslaw 11.08.2010

INDIVIDUAL OPT-OUT

Any other employment must be declared to us as it will affect this agreement.

I ………………Rajchert Przemyslaw………………………………….. agree that in respect of my

employment with Primo Executive Recruitment.

My average weekly working hours may exceed 48 hours (includes overtime).

This agreement amends my existing Contract of Employment and will apply from the date of signing.

I will comply with any policies, from time to time in force, which relate to the maintenance of records of
my hours of work.

I may give the company 3 months notice in writing to terminate this Agreement.

Signature: Date:

Rajchert Przemyslaw 11.08.2010

Details of your option will be stored on our computer system and will be used to process information
relevant to working time and also will be used for payroll processing.
Guidance for Applicants Section

Accessibility and Recruitment

We want to ensure that all candidates have equal access to our recruitment and selection procedures.
If you have a disability, impairment or long-term health condition that may affect your ability to
complete this form, or if you require any adjustments to enable you to attend an interview or
participate in the selection process, please send details as soon as possible to the Recruitment Officer
(our contact details are shown below). This will enable us make any reasonable adjustments.

Accessibility and Employment

We recognise that some disabled staff members may require some practical adjustments, once they
are in a role, to enable them to carry out their job. If, during the recruitment process, you would like to
discuss any adjustments that you might require to enable you to carry out the role you are applying
for, you are welcome to contact the Recruitment Officer to discuss this further. Our contact details are
shown below.

Health
If you have a health condition that may affect your work or ability to carry out the duties associated
with this post, please contact the Recruitment Officer (our contact details are shown below) to provide
more information.

Criminal Convictions
In most cases a spent criminal record need not be declared. However, certain posts are exempt from
the Rehabilitation of Offenders Act 1974 and even a spent criminal record must be disclosed. The
Further Particulars for the post will indicate whether the post for which you are applying for is exempt.

For all posts, please submit as a separate document full details of any unspent criminal convictions or
any criminal proceedings that are pending against you. In addition, for exempt posts, please provide
full details of any spent convictions. On this document, please state clearly your full name the job
reference number and job title of the post for which you are applying. This document should either be
sent in an envelope marked “Private and Confidential” to the Recruitment Officer or e-mailed (our
contact details are shown below).

Contact Details:

Primo Executive Recruitment

Calder House,
8 South Caldeen Road,
Coatbridge,
ML5 4EG,

Tel: 0844 811 0511

Fax: 0844 811 0512