Please answer ALL of the following questions in order that we may identify those assignments which are most suitable for you.

I confirm that the above answers are true and accurate, and I understand that any misrepresentation could result in the termination of my employment and the possibility of my employer seeking damages for any misrepresentation I have made as to my state of health.

I further understand that the information provided on this form will be relied on by my employer, and will assist them in complying with our joint obligation to ensure that employees work in a safe environment.

Further I understand that any misrepresentation or failure to disclose any information requested on this form can be viewed as a serious disciplinary matter and can warrant disciplinary action being taken up to and including dismissal without notice on grounds of gross misconduct.

Finally, I give my express consent for my employer to process the information contained within this form and understand that the employer processes this information to ensure that they are able to maintain a safe environment of work under their obligations under Health and Safety legislation.