CEVA Starter Documents Form CEVA Starter Documents Your Details (Confidential)Full Name* First Email* Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Name & address of your own general practitioner* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Data Protection: The information you provide on this form will be used by the Company for the purpose of assessing your fitness for work and will be handled in line with the Company’s Data Protection Policy. In order for us to fulfil our contractual and/or legal obligations to you, it may be necessary to share some of this information with medical or healthcare professionals, should advice be needed to validate your fitness to undertake your role, or in support of any reasonable adjustments that may be required. In the event that this is necessary, we will seek your consent. This document will be kept on your personnel file (hard copy and/or electronic) for the duration of your employment. We will retain your personnel file for a period of 7 years after your employment has ended (or in line with current legislation at that time). Please refer to the Company’s Data Protection Policy for more information relating to how the Company processes your personal data and your rights. Have you ever suffered from, or had any symptoms of the following:If YES, please give full details – use another sheet if necessary If NO, please mark NA (Not Applicable) 1. Disturbed sleeping patterns requiring medical attention?* Yes No Please elaborate if the answer is YES2. Have you worked / do you work a permanent/rotating night shift pattern?* Yes No Please elaborate if the answer is YES3. Any medical condition requiring medication to a strict timetable?* Yes No Please elaborate if the answer is YES4. Has your work ever had a direct adverse effect on your health? E.G vibration white finger, noise induced hearing loss or work related stress.* Yes No Please elaborate if the answer is YES5. Problems with the ears, eyes? Any defect of hearing or sight?* Yes No Please elaborate if the answer is YES6. Have you consulted or been referred to a medical or surgical specialist in the last 2 years?* Yes No Please elaborate if the answer is YES7. Have you had any serious injuries? Fracture, head injury, etc.?* Yes No Please elaborate if the answer is YES8. Any nose, throat or chest illnesses? E.g. Hay fever, tonsillitis?* Yes No Please elaborate if the answer is YES9. Any stomach, bowel or intestinal trouble, e.g. ulcer, attacks of diarrhoea, chronic indigestion?* Yes No Please elaborate if the answer is YES10. Have you had a nervous breakdown or suffer with any other mental illness?* Yes No Please elaborate if the answer is YES11. Have you suffered from migraine, fits, attacks of unconsciousness or dizziness?* Yes No Please elaborate if the answer is YES12. Do you have sensitivity to chemicals? e.g. detergent* Yes No Please elaborate if the answer is YES13. Do you have any skin trouble? E.g. Eczema, Dermatitis?* Yes No Please elaborate if the answer is YES14. Have you suffered from heart trouble, high blood pressure, circulatory problems or diabetes?* Yes No Please elaborate if the answer is YES15. Do you suffer from lumbago, sciatica, or other prolonged back pain?* Yes No Please elaborate if the answer is YES16. Have you had a rupture (Hernia)?* Yes No Please elaborate if the answer is YES17. Do you suffer from any known allergies?* Yes No Please elaborate if the answer is YES18. Do you have any breathing difficulties? e.g. Asthma* Yes No Please elaborate if the answer is YES19. Are you having, or waiting for any medical treatment or investigations at present?* Yes No Please elaborate if the answer is YES20. Do you have any serious illness not included in the above questions?* Yes No Please elaborate if the answer is YES21. Are there any other health factors that might affect your fitness for work?* Yes No Please elaborate if the answer is YES22. Do you have or have you ever had any significant health problem, impairment/disability (physical or mental) or learning difficulties that may affect your ability to undertake the tasks set out in the job description of the post offered?* Yes No Please elaborate if the answer is YES23. Will you need any special aids or adjustments or assistance to enable you to undertake the tasks set out in the job description of the post offered?* Yes No Please elaborate if the answer is YESDECLARATION: I declare that the information given on this document, is to the best of my knowledge, a true and complete account of my medical history and that failure to disclose details of my medical history may prejudice continued employment with the Company. TO CONTINUE PLEASE CLICK SUBMIT AND READ THROUGH THE DOCUMENT THEN SIGN AT THE BOTTOM. CLICK AGREE AND SIGN THIS WILL SEND THE DOCUMENT BACK TO IGLOO
