HR 2.

01 F4 -- Pre- Employment Medical Questionnaire

Please complete the enclosed Questionnaire and return the form to ourselves.

Please supply us with the following information and/or documentation, if applicable to yourself,
and return with your signed contract to this office.

a) NAME

DATE OF BIRTH

b) SINGLE/MARRIED/WIDOWED/DIVORCED
(Required for pension purposes, please delete where applicable)

SPOUSE’S NAME

SPOUSE’S DATE OF BIRTH

DATE OF MARRIAGE/DIVORCE

MAIDEN NAME

c) Copy of marriage certificate

d) Number of children
Sex and dates of birth of children:

1) MALE/FEMALE DATE OF BIRTH

2) MALE/FEMALE DATE OF BIRTH

3) MALE/FEMALE DATE OF BIRTH

4) MALE/FEMALE DATE OF BIRTH

e) Copy (ies) of birth certificates for children

f) Copy of your own birth certificate