Dex Application Form

1
Name:* This field is required.Enter Name
First Name
Last Name
2
Address:* This field is required.Example: 10 Downing Street London - then select your address, DO NOT PUT IN POSTCODE FIRST
Street Address
Street Address Line 2
City
Country
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
When did you move in to this address?* This field is required.
Date
Day
Month
Year
4
Previous Address if less than 5 years:If you’ve been in your current address more than 5 years leave this section blank and click NEXT
Street Address
Street Address Line 2
City
Country
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Phone Number:* This field is required.
Example: 07711223344
6
E-mail Address:* This field is required.
7
National Insurance Number:* This field is required.Type NO if you do not have one
Example AA123456A
8
Date of Birth:* This field is required.We need these details for your CRB Check - Date of Birth - DD/MM/YYYY
Date of Birth
Day
Month
Year
9
Marital Status:* This field is required.Required as part of our system input
Please Select
Please Select
Married
Widowed
Single
Living with Partner
Marital Status
10
Gender Details:* This field is required.Required as part of the system selection
Please Select
Please Select
MALE
FEMALE
GENDER DIVERSE
Gender Details
11
Nationality Details:* This field is required.We need these details for your CRB Check
British
Please Select
British
Afghan
Albanian
Algerian
American
Andorran
Angolan
Anguillan
Argentine
Armenian
Australian
Austrian
Azerbaijani
Bahamian
Bahraini
Bangladeshi
Barbadian
Belarusian
Belgian
Belizean
Beninese
Bermudian
Bhutanese
Bolivian
Botswanan
Brazilian
British
British Virgin Islander
Bruneian
Bulgarian
Burkinan
Burmese
Burundian
Cambodian
Cameroonian
Canadian
Cape Verdean
Cayman Islander
Central African
Chadian
Chilean
Chinese
Citizen of Antigua and Barbuda
Citizen of Bosnia and Herzegovina
Citizen of Guinea-Bissau
Citizen of Kiribati
Citizen of Seychelles
Citizen of the Dominican Republic
Citizen of Vanuatu
Colombian
Comoran
Congolese (Congo)
Congolese (DRC)
Cook Islander
Costa Rican
Croatian
Cuban
Cymraes
Cymro
Cypriot
Czech
Danish
Djiboutian
Dominican
Dutch
East Timorese
Ecuadorean
Egyptian
Emirati
English
Equatorial Guinean
Eritrean
Estonian
Ethiopian
Faroese
Fijian
Filipino
Finnish
French
Gabonese
Gambian
Georgian
German
Ghanaian
Gibraltarian
Greek
Greenlandic
Grenadian
Guamanian
Guatemalan
Guinean
Guyanese
Haitian
Honduran
Hong Konger
Hungarian
Icelandic
Indian
Indonesian
Iranian
Iraqi
Irish
Israeli
Italian
Ivorian
Jamaican
Japanese
Jordanian
Kazakh
Kenyan
Kittitian
Kosovan
Kuwaiti
Kyrgyz
Lao
Latvian
Lebanese
Liberian
Libyan
Liechtenstein citizen
Lithuanian
Luxembourger
Macanese
Macedonian
Malagasy
Malawian
Malaysian
Maldivian
Malian
Maltese
Marshallese
Martiniquais
Mauritanian
Mauritian
Mexican
Micronesian
Moldovan
Monegasque
Mongolian
Montenegrin
Montserratian
Moroccan
Mosotho
Mozambican
Namibian
Nauruan
Nepalese
New Zealander
Nicaraguan
Nigerian
Nigerien
Niuean
North Korean
Northern Irish
Norwegian
Omani
Pakistani
Palauan
Palestinian
Panamanian
Papua New Guinean
Paraguayan
Peruvian
Pitcairn Islander
Polish
Portuguese
Prydeinig
Puerto Rican
Qatari
Romanian
Russian
Rwandan
Salvadorean
Sammarinese
Samoan
Sao Tomean
Saudi Arabian
Scottish
Senegalese
Serbian
Sierra Leonean
Singaporean
Slovak
Slovenian
Solomon Islander
Somali
South African
South Korean
South Sudanese
Spanish
Sri Lankan
St Helenian
St Lucian
Stateless
Sudanese
Surinamese
Swazi
Swedish
Swiss
Syrian
Taiwanese
Tajik
Tanzanian
Thai
Togolese
Tongan
Trinidadian
Tristanian
Tunisian
Turkish
Turkmen
Turks and Caicos Islander
Tuvaluan
Ugandan
Ukrainian
Uruguayan
Uzbek
Vatican citizen
Venezuelan
Vietnamese
Vincentian
Wallisian
Welsh
Yemeni
Zambian
Zimbabwean
Please select
12
Number of years of continuous residence in the UK * This field is required.Select from drop down
Lived in the UK my whole life
Lived in the UK my whole life
1
2
3
4
5
6
7
8
9
10 +
13
Next of Kin:* This field is required.Important Details
Name
Relationship
Contact Number
14
Right to Work DetailsWe require a clear image of your Right to Work Documents (Passport / EEA Passport British Birth Certificate National ID Card), Click Next
15
Take PhotoPlease take a clear picture of your Right to Work Documentation
16
Work History:* This field is required.We only need the last two, if you have more than two there is another page click next
First Company Name
Job Title
From MM/YY
To MM/YY or Present/ Current
17
Work History:We only need the last two, if you have more than two there is another page click next
Second Company Name
Job Title
From MM/YY
To MM/YY
18
References: 1st Reference* This field is required.Don't worry if you don't have all the information, we need just enough to make contact with them,
Name
Relationship to you
Email - If you don't no their email then type your email again.
Contact number
19
References: 2nd ReferenceDon't worry if you don't have all the information, we need just enough to make contact with them,
Name
Relationship to you
Email - If you don't no their email then type your email again.
Contact number
20
Have you previously worked for our agency in the last 6 months?* This field is required.
YESNO
21
Epilepsy * This field is required.
NOYES
22
Fit(s) or blackouts* This field is required.
NOYES
23
Severe and recurrent disabling giddiness* This field is required.
NOYES
24
Diabetes controlled by insulin* This field is required.
NOYES
25
Diabetes controlled by tablets* This field is required.
NOYES
26
An implanted pacemaker or defibrillator* This field is required.
NOYES
27
Angina (heart pain) which is easily provoked by driving* This field is required.
NOYES
28
Persistent alcohol misuse or dependency* This field is required.
NOYES
29
Persistent drug misuse or dependency* This field is required.
NOYES
30
Parkinson’s disease* This field is required.
NOYES
31
Narcolepsy or sleep apnea* This field is required.
NOYES
32
Stroke, with any symptoms lasting longer than one month, recurrent “mini strokes” or TIAs* This field is required.
NOYES
33
Any type of brain surgery, severe head injury involving in-patient treatment, or brain tumor* This field is required.
NOYES
34
Any other chronic neurological condition* This field is required.
NOYES
35
A serious problem with memory or episodes of confusion* This field is required.
NOYES
36
Serious psychiatric illness or mental ill health for example diagnosis of anxiety/depression which required treatment from your GP/Specialist* This field is required.
NOYES
37
Any visual condition affecting BOTH eyes or affecting your peripheral vision (visual field) (excluding short/long sight or colour blindness)* This field is required.
NOYES
38
Any persisting limb problems which requires your driving to be restricted to certain types of vehicle or those with adapted controls* This field is required.
NOYES
39
Sight in one eye only* This field is required.
NOYES
40
Visual problems affecting either eye* This field is required.
NOYES
41
Angina, other heart condition or heart operation* This field is required.
NOYES
42
Any form of stroke, including minor or TIA* This field is required.
NOYES
43
Health Declaration * This field is required.I confirm that the information given above is a true and accurate statement. I understand that if I have declared any of the conditions listed above, further medical investigations may take place. I understand I must inform you immediately if MY state of health and condition alters from that stated above, any time after the date of this declaration.
44
Do you have a driving licence?* This field is required.Select YES or NO
YESNO
45
Is there a restriction # 1 on the drivers licence?* This field is required.Check the drivers licence If there is a restriction # 1 then the driver should wear corrective lenses or glasses for the test
NOYES
46
Can the driver see a normal number plate at 20 meters?* This field is required.If the driver can’t see the number plate advise them they should refer to an optician. Refuse to let them drive any company vehicle and fail the test.
YESNO
47
Is your Licence a Full UK or Full EU/ None EU Licence?* This field is required.Please select
UKEU or None EU
48
Have you had any accidents, thefts or losses (whether covered by the insurance or not and regardless of blame) during the past 5 years?* This field is required.If YES, please give full details including costs.
NOYES
49
Have you ever been disqualified from driving OR in the past 5 years been convicted of any offence concerned with a motor vehicle OR, is any police enquiry or prosecution pending. State offence, date, penalty and period of suspension? * This field is required.if YES state offence, date, penalty period of suspension.
NOYES
50
Have you been diagnosed with any physical or mental condition which may impair their ability to drive?* This field is required.If YES, has a General Practitioner declared you fit to drive or has the condition been reported to the Driver Licence Authority who have continued to issue a licence?
NOYES
51
Has any motor insurance ever been declined, cancelled or refused or has an increased premium been charged, or any special terms imposed? * This field is required.If YES, please give full details.
NOYES
52
Endorsement Details* This field is required.Driving Licence Details - If you can't drive leave blank and click NEXT.
Please Select
Please Select
I have no points
1 Point
2 Points
3 Points
4 Points
5 Points
6 Points
7 Points
8 Points
9 Points
10 Points
11 Points
12 Points
Endorsements/ Points on your Licence
Please Select
Please Select
YES
NO
Have you ever had an IN10
Please Select
Please Select
YES
NO
Have you ever had an DR10, DR20, DR30
53
Take a clear photo of the FRONT of your Driving LicenceThis is used for application purposes only
54
Take a clear photo of the BACK of your Driving LicenceThis is used for application purposes only
55
Do you hold a valid CPC (Driver Certificate of Professional Competence)? * This field is required.Select YES or NO
YESNO
56
When does your CPC (Driver Certificate of Professional Competence) ExpireEnter Expire Date
Date
Day
Month
Year
57
Take a clear photo of the FRONT of your CPC (Driver Certificate of Professional Competence) CardThis is used for application purposes only
58
Take a clear photo of the BACK of your CPC (Driver Certificate of Professional Competence) CardThis is used for application purposes only
59
Take a clear photo of the FRONT of your Tachograph CardThis is used for application purposes only
60
Have you been convicted of a criminal offence in this or any other country?* This field is required.
NOYES
61
Have you been convicted of any offence under the Aviation Security Act 1990?* This field is required.
NOYES
62
Have you ever received a caution from the police within the last 5 years?* This field is required.
NOYES
63
GDPR Us of Data Terms and Conditions* This field is required.We will only use your ID and Licence for the purpose of this application
64
Bank Details* This field is required.DOUBLE CHECK THESE DETAILS
BANK NAME - E.I - Santander
ACCOUNT NAME
SORT CODE
ACCOUNT NUMBER
65
Agreement for Work Finding Services* This field is required.I hereby consent to the passing of my personal data, and sensitive personal data as appropriate, to prospective hirers and Deliverex as described in this Data Protection Consent Form
66
SignatureI understand that the Agency will pass my personal data to an Employment Management Company plus any Payroll Service Providers
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