Employment Application

ALLEGRO DELIVERY SHIPPING COMPANY -- Please print clearly

Position Apply

Your details

Family Name *
Male [_] Female [_]

First Name* Middle Name* Passpor t Number *

Contact Phone * Date Of Birth* DD / MM / YYYY

Full Home Address *

Town* State* Post Code*

Right to work in US* Not Inadmissible: Yes [_] No [_]

How many days can you work each week? Can you start work anytime soon?

5/7 days [_] 3/4 days [_] Yes [_] No [_]

Have you worked for us before? Yes [_] No [_] If yes specify Post held:

Emergency contact / Next of Kin

Name*

Phone*

We collect this information to assess your suitability for employment, to your identity, and to create
your employment record. It will be kept confidential and not used for any other purpose without your
permission, except as required by law.
Have you been convicted of a criminal offence in the last 10 years?*
Details
Yes [_] - give details No [_]

Do you have any medical condition that might affect fellow workers or food safety?*
Details
Yes [_] - give details No [_]

Do you have any allergies? (For example to bees, fruit, pollen, dust, nuts or chemicals)*

Details
Yes [_] - give details No [_]

Do you have any chronic pain, such as back pain or shoulder pain, or any other medical condition that
may get worse with hard or repetitive physical work?*

Details
Yes [_] - give details No [_]

Do you take any medications that may affect performance or place you or others at risk?*

Details
Yes [_] - give details No [_]

For the purposes of supporting you in an emergency, do you have any medical condition which we should
know about? (Such as diabetes, heart problems, epilepsy etc.)*

Details
Yes [_] - give details No [_]

Do you now, or have you ever had a worker’s compensation claim against any employer?*

Yes [_] - If “yes” to either question give details No [_]

Date Employer Injury Period of Absence Insurer

It is a condition of employment that the company may conduct health monitoring programs
including drug and alcohol testing. Do you agree to participate in health monitoring programs
authorized by the company?*

Yes [_] No [_]

Do you have a current driver’s license? Yes [_] No [_]
Licenses, permits, certificates (e.g. Forklift License, First Aid Certificate)

Skill or Qualification Where Obtained Type or Level

Work history
Position Company Length of Time

References

Name / Position Company Phone

What is your e-mail address?

The information about myself provided in this application is true. I authorize the company to
verify it. I agree to abide by all safety instructions and company rules.
DD / MM / YYYY
Signature of Applicant* Date*

ALLEGRO DELIVERY SHIPPING COMPANY

Allegro Delivery Shipping Company,
111 W. Jackson Suite 1700, Chicago, IL, 60604, USA

www.allegrotracking.com
+ (773) 823-4340

hrd@allegrotracking.com