Title

Name

Date of Birth Date of Birth

Sex Sex Male Female

Phone Number

Email

Mobile Number

Nationality Please note it is your responsibility to inform us of any change in job title or description

Job Title Please note it is your responsibility to inform us of any change in job title or description

National Insurance Number

S H A R E Code

Documents File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, png, mka, xla, xls, xlt, xlw, mdb, onetoc, onetoc2, onetmp, onepkg, oxps, odg. Max. file size: 16 MB

Professional Qualifications Held

Qualification Documents Attach your certificates hereFile InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, png, mka, 7z, xla, xls, xlt, xlw, mdb. Max. file size: 16 MB

Street

Town

Postcode

Street

Town

Postcode

Name of Bank/Building Society

Branch Location

Name of Account Holder

Sort Code

Account Number

Roll Number

Unique Tax Reference Number (UTR)

CIS Account Name

CIS Trading Name

Are you VAT Registered Are you VAT Registered Yes No

CIS VAT Certificate File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, png, mka, gz, gzip, 7z, xla, xls, xlt, xlw, mdb, onetoc, onetoc2, onetmp, onepkg, wp, wpd. Max. file size: 16 MB

Agency Name

Is the Assignment Is the Assignment UK Based Abroad Offshore

How would you classify the assignment How would you classify the assignment Trade Technical Professional Rail

NMC PIN NMC PIN

Name of last school attended

Mother’s maiden name

Town of Birth

How did you hear about us? How did you hear about us? Agency Workmate/Colleague Previous User Online Communication

Next of Kin Name

Next of Kin Home Number

Next of Kin Contact Permission Next of Kin Contact Permission Please tick this box if you would like to nominate your next of kin to be able to speak on your behalf at times regarding personal information such as your payments. Yes No

Next of Kin Mobile Number

Have you ever been convicted of a criminal offence? Have you ever been convicted of a criminal offence? Yes No

Criminal Conviction Details Please detail criminal convictions

How many assignments have you completed in the last 12 months using your UTR No?

Would you be entitled to Holiday pay, sick pay, a company pension scheme or other such benefits? Would you be entitled to Holiday pay, sick pay, a company pension scheme or other such benefits? Yes No

Are you responsible to complete, either yourself or via an accountant, an annual self-assessment tax return? Are you responsible to complete, either yourself or via an accountant, an annual self-assessment tax return? Yes No

Are you under any obligation to accept or receive future assignments from the Client or the Agency? Are you under any obligation to accept or receive future assignments from the Client or the Agency? Yes No

Are you responsible for all your own expenses in relation to travelling to/from site and/or overnight accommodation? Are you responsible for all your own expenses in relation to travelling to/from site and/or overnight accommodation? Yes No

Do you understand that a suitably qualified alternative contractor can be supplied as a substitute to complete a task that you Do you understand that a suitably qualified alternative contractor can be supplied as a substitute to complete a task that you Yes No

Do you provide your own tools, equipment and/or PPE to carry out your assignments?* Do you provide your own tools, equipment and/or PPE to carry out your assignments?* Yes No

Do you have the freedom to contract on more than one assignment at any one time and choose the hours you work taking into acc Do you have the freedom to contract on more than one assignment at any one time and choose the hours you work taking into acc Yes No

Once given basic instructions of what to do for your day, will anyone else advise you how to complete these tasks? Once given basic instructions of what to do for your day, will anyone else advise you how to complete these tasks? Yes No

Do you receive training with the exception of H&S training from anyone you currently provide services to?** Do you receive training with the exception of H&S training from anyone you currently provide services to?** Yes No

Will you be under constant supervision by anyone whilst undertaking your role? Will you be under constant supervision by anyone whilst undertaking your role? Yes No

I Agree I Agree Yes No

Date Date

Signature Please sign and save your signature SaveClear