All candidates are required to complete the following questionnaire. All information will be treated privately and confidentially. All candidates are asked to answer each question by placing a tick in the relevant box. Should you answer Yes for any question, please give full details in the space provided on the next page.

Have you suffered or are you suffering from any of the following?

Declaration

I understand and acknowledge that should I knowingly make a false statement regarding my medical history either in answering the above questions or to any medical examiner, or should I wilfully conceal any material fact, I will if engaged be liable to have my contract terminated. In the event of any health queries I consent to my general practitioner supplying relevant information to the company medical advisor. I confirm that there is nothing in my current circumstance that would be detrimental to me working either on a shift roaster basis throughout the night.