POSITION

Applying for the position as:

PERSONAL DETAILS
Surname: Given Names:

Address:

Postcode:

Phone
Numbers: (Work) (Home) (Mobile)

Email:

Marital Status: Married / Defacto / Single Number of dependents:

Date of Birth: ________________ Place of Birth: ______________

Are you an Australian citizen: Yes  No  If not, do you hold either of the following:

Work visa for Australia? Yes  No  Permanent residence visa Yes  No 

Do you own a motor vehicle: Yes  No  Class of Licence held:

Licence Number: Expiry Date:

How did you hear about this position?

Newspaper:  Seek:  Internet: 

Referred by: _________________________________ Other: ______________________________________

HISTORY AND EMPLOYMENT DETAILS

DATES: From - To - COMPANY DUTIES

May we contact any of the employers listed above? Yes  No 

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Declarations:
The following declarations are not intended to prevent people gaining employment with this organisation, but will
assist us to take due care in assessing the most appropriate placement.
Health:
(if no please provide details)
To the best of your knowledge are you of sound
health? Yes  No 
(if yes please provide details)
Have you been an in-patient in a health care facility
within the last twelve months? Yes  No 
(if yes please provide details)
Have you ever suffered any series or life-
threatening illnesses? Yes  No 
(if yes please provide details of
Are you a smoker? Yes  No  periods of usage and quantity
smoked)

Disability:
(if yes please provide details)
Do you have a disability or previous injury likely to
be aggravated by the type of work for which you are
applying, or for which you may have special needs Yes  No 
in regard to work design or modification?

Convictions:
(if yes please provide details)
Do you have any criminal convictions? Yes  No 
(if yes please provide details)
Do you have any traffic convictions? Yes  No 
(if yes please provide details)
Are you currently the subject of any pending
charges? Yes  No 
Entitlement to work in Australia:
(if yes please provide your birth certificate, and either a current
Are you entitled to work in Australia? Yes  No  Australian passport, current permanent residence visa, or a
current work visa for Australia)

Workers’ Compensation Claims:

Section 79 of the Workers’ Compensation and Rehabilitation Act 1981 states “Where it is proved that the worker
has, at the time of seeking or entering employment in respect of which he claims compensation for a disability,
willfully and falsely represented himself as not having previously suffered from the disability a dispute resolution
body may in its discretion refuse to award compensation which otherwise would be payable”.

Have you read the above statement? Yes  No 

(if yes please provide details)
Have you ever made a claim for workers’
compensation? Yes  No 

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Education Details:
a) Secondary
School: Level Attained: Year Completed:

b) Tertiary/Training
Institution: Qualifications: Year Completed:
(if completed)

c) Apprenticeship
Name of Company: Training Undertaken: Year Completed:

References:
Referees: (not to be family or friends)

1) Phone Number:

2) Phone Number:

3) Phone Number:

How much notice are you required to give to your current employer? __________ Weeks

I acknowledge by submitting this application that I am declaring all statements in the application to be
true in all respects. I acknowledge that any statement which is found to be false or deliberately
misleading will make me, if employed, liable for dismissal. I am prepared to attend a medical and alcohol
and other drug testing part of my application.

Signature of Applicant: _______________________ Date: ____________________

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