CK2J Recruitment
Old Church School,
Butts Hill, Frome,
Somerset  BA11 1HR
Tel: 01373 470 171

Mob: 07825 001 572
Medical Declarations
Are there any medical reasons, or are you currently taking any medication, that might affect your ability to work nights?
Yes No
If yes, please give details:
Unspent Convictions
Do you have any convictions that are unspent under the Rehabilitation of Offenders act 1974?
Yes No
If yes, please give details / dates of offence(s) and sentence:
Signed: Date: