Contractor Area

Unique Tax Reference Number

Do you have a full driving license?

Yes No

License Picture (Upload a picture of the front of your license)

Car/Van registration (if used for business purposes)

Are you eligible to work in the UK?

Yes No

Please upload a picture of your passport/permit to work

Emergency Contact 1 Name

Emergency Contact 2 Name

Please tick boxes regarding job hazards

Do you, or have you ever suffered from any of the following: (Please provide further details on the last page)

Yes No

Tuberculosis, pleurisy, asthma, bronchitis, or any other lung, throat or ear complaint, including deafness

Yes No

Any disorder of the heart, circulatory system, high blood pressure

Yes No

Persistent indigestion, gastric or duodenal ulcer, intestinal complaint or rupture

Yes No

Epilepsy or fits

Yes No

Any psychological or nervous complaint

Yes No

Diabetes, gout or any kidney or bladder complaint

Yes No

Any arthritis, slipped disc, rheumatism, back trouble, or upper limb problem

Yes No

Dermatitis, other skin complaint or allergic condition

Yes No

Sleep apnoea, narcolepsy or cataplexy

Yes No

Frequent headaches or migraine

Yes No

Any eye complaint including blurred vision or eye discomfort

Yes No

Any other significant medical problem

Yes No

Do you normally wear glasses or contact lenses?

Yes No

When did you last have an eye test?

Do you have any difficulty in recognising different colours?

Yes No

Have you ever consulted or been recommended to consult a medical specialist?

Yes No

With reference to the Disability Discrimination Act, do you have any physical or mental impairment, which significantly affects your daily living?

Yes No

Are you currently on any prescribed treatment?

Yes No

Additional Information

Occupational History

Worked in a dusty environment

Yes No

Worked in a noisy environment

Yes No

Worked with chemicals

Yes No

Worked with x-rays or other forms of radiation

Yes No

Worked with vibrating tools

Yes No

Been advised for medical reasons not to do any specific kind of work?

Yes No

Undergone health surveillance due to hazards at your previous job?

Yes No

How many days have you been unable to attend work or undertake normal daily tasks through sickness?

Data Protection Declaration Statement

Under the GDPR Regulations, the information you supply about yourself in this form is known as your personal data and information about your health, medical history and any treatment you have received is ‘sensitive personal data’.

This form may used to assess your health & fitness for the position, and also ensure correct health surveillance is put into place for your wellbeing. Your consent is required before this processing can take place.

Declaration - PLEASE READ CAREFULLY

By signing this declaration, you will be giving your consent to the processing of the information you have supplied. If you do not understand the content of this form, the content or the effect of the declaration or you feel unable to give your consent, please contact HR.

I CONFIRM THAT I HAVE READ AND UNDERSTOOD THE DATA PROTECTION NOTICE ABOVE. I HEREBY AGREE AND CONSENT TO THE PROCESSING OF THE INFORMATION THAT I HAVE SUPPLIED ABOUT ME.

I declare that all the foregoing statements are true and complete to the best of my knowledge and belief and I am not aware of any other medical condition not referred to elsewhere in this questionnaire. I understand that any misrepresentation will invalidate my application and if employed, could lead to my dismissal. I understand that I may be required to undergo a medical examination by the company’s appointed medical adviser for health surveillance purposes.

I accept the statement above

Please Attach CSCS card/Skills Card (Front and Reverse)

Please attach any other relevant training cards/certificates

Please contact us for your sub-contractor agreement

I have read and agree to the Sub-Contractor Agreement.

Please upload/take photograph for site ID

ID cards

I understand that ID cards must be visible on-site at all times

Hi Vis two-tone polo shirts

Hi Vis two-tone vest

You will be issued with the following items of workwear:

4 x navy t-shirts
2 x Hi Vis two-tone polo shirts
1 x navy sweatshirt
1 x Hi Vis two-tone vest
Mahoney’s PPE holdall
1 x hard hat
1 x Diaego safety glasses
1 x safety goggles
1 x ear defenders
1 x ear plugs
1 x dust mask
1 x EC9 puggy type gloves
1 x first aid kit

I understand it is of my own responsibility to ensure that all of the above items are kept within my possession and of good working condition.
Any replacements may be sourced through the company for fair wear and tear. Any misuse will be charged and deducted.
I understand that at least one Hi Vis item of clothing must be worn visibly at all times.
I understand that correct PPE must be worn at all times.

Workwear

I agree to the above conditions for workwear.

Please download a timesheet.
Click to download Time Sheet
Timesheets are also available in the main office.

Time Sheet Hand In

I understand that timesheets must be completed and handed in each week by Tuesday at 1pm at the latest, in order for payment to be made for Friday. I understand that timesheets received after this time will result in a delay in payment being made.

Time Sheet Job References

I understand that timesheets must have job references on, and to contact the office or my Site Manager if I am unaware of a job reference, prior to submitting. I understand failure to complete a timesheet correctly will result in no payment for the related hours.

Do you have public liability insurance suited to the works you carry out?

Yes No

Please upload a copy of your insurance

As part of your agreement with the company, every sub-contractor must ensure that he/she has adequate and appropriate insurance cover, to include valid public liability and (if applicable) employer’s liability insurance certificates, copies of which must be made available to the company.

The sub-contractor must ensure that he/she has insurance to cover any loss, damage, etc. which may occur whilst rendering services under this agreement, as the company is unable to accept any responsibility for loss of personal property and/or effects etc.

The company will source insurance cover on behalf of sub-contractors if preferred. The cost will then be deducted from the sub-contractor’s wage, and an invoice will be supplied for personal accounts.

The standard public liability package we will organise will cover the following:

Works on private dwellings, block of flats, shops, offices, surgeries, hotels, guest houses, public houses, restaurants, cafes, take-aways, wine bars, social clubs and nursing homes
Works carried out within the EU
Indemnity limit - £1,000,000
Excess of £500

Additional extras may include:

Work on gas appliances
Working at height
Working below ground
3 phase electrical work
Use of woodworking machinery other than hand held tools

The standard tools liability package we will organise will cover the following:

Loss or damage to powered and non-powered hand-held tools of all types belonging to, leased to, on hire purchase, loan or hired to you or your employees
Theft from any vehicle, provided that the doors of the vehicle are locked, and all its windows and other openings are fully closed and properly fastened
Our policy does not cover damage to any tool caused by its own breakdown or explosion, or loss by disappearance or by shortage which is only discovered by a routine inventory or periodic stock-taking. Tools are also not covered whilst unattended in an unlocked open environment.
Level of cover - £2,000
Excess of £250

Please note: The company will be unable to gain insurance cover for any person that:

Are subject to bankruptcy or insolvency orders which are either outstanding or have been discharged for less than 5 years;
have been convicted of or charged (but not yet tried) with a breach of any health and safety legislation or any other criminal offence other than parking or speeding offences or offences which are spent under the Rehabilitation of Offenders Act 1974;
have ever had a proposal refused or declined or ever had an insurance cancelled, renewal refused or had special terms imposed;
have been the subject of a County Court Judgement and/or ever been cited in any unsatisfied court judgements (or the Scottish equivalent) within the last 10 years;
have been subject of an individual voluntary arrangement with creditors, voluntary liquidation, a winding up or administration order, or administrative receivership proceedings within the last 10 years

Full details of the insurance policies will be provided to the sub-contractor. Please complete the following, and if applicable, provide evidence to the company:

Public Liability & Tools Insurance Cover

I will organise my own public liability/tools insurance, and will provide a copy of policy/policies to the company, and each year upon renewal I wish for the company organise public liability insurance ONLY, on my behalf I wish for the company to organise BOTH public liability insurance and tools insurance cover

I can confirm I have received the company handbook along with the relevant policies and procedures.

I understand that I am responsible for reading the company handbook, familiarising myself with its contents, and adhering to the policies and procedures of Mahoney Contracts.

The policies, procedures and standard practices described are not conditions of employment. The handbook does not create an express or implied contract between Mahoney Contracts and any of its employees.

I understand that the information in this handbook represents guidelines only. Mahoney Contracts reserves the right to modify this handbook, amend or terminate any policies and procedures at any time.

I understand that Mahoney Contracts review the company handbook, policies and procedures annually, and up-to-date copies must be accessed from the HR department hereafter.

I understand that all related documents are the property of Mahoney Contracts, and are to be returned to the HR Department should my employment/contract be terminated.

Do you understand and accept the terms above?

I accept the terms above

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