Application Form

Fields marked * are required

Date of Application :
Position Applied for :
REQUIREMENTS OF THE POSITION: Working in the outdoors; Digging; Bending; Lifting, Carrying, Pushing and Pulling loads; Using manual tools such as shovels, spades and rakes etc; Operating equipment such as lawn mowers, edgers and augers etc; Administration tasks such as time sheets and reports; Working with chemicals.
PERSONAL DETAILS
Title
Given Names*
Surname*
Address
PostCode
Telephone Number*
Mobile Number
Email*
Date Of Birth*

Drivers License Number

Class

Expiry
A COPY OF YOUR CURRENT DRIVERS LICENSE WILL BE REQUIRED BEFORE COMMENCEMENT DATE
Do you hold a "Blue/White card"?
Expiry
Number
IT IS A CONDITION OF EMPLOYMENT TO HOLD A CURRENT BLUE/WHITE CARD.
A COPY OF YOUR CURRENT CARD WILL BE REQUIRED FOR YOUR INDUCTION.
Do you hold a "First Aid" Certificate?
Expiry
EDUCATION AND QUALIFICATION DETAILS
Please list details of schools, colleges attended and qualifications
EDUCATION INSTITUTION ATTENDED QUALIFICATION ATTAINED DATE OF ATTENDANCE
Secondary
Apprenticeship
Tertiary
Certificates/Diplomas
PREVIOUS EMPLOYMENT HISTORY
LIST 3 PREVIOUS EMPLOYERS (Including current position and notice period required)
  NAME AND ADDRESS
OF EMPLOYER
YEAR
 POSITION AND BRIEF
DETAILS OF DUTIES 		REASON FOR LEAVING
FROM TO
1)
2)
3)
BRIEF LIST OF EQUIPMENT WORKED ON
Please provide details of the basis for your ability to work in Australia (eg Australian citizen or holder of appropriate working visa {provide details of passport, visa type and number})
MEDICAL INFORMATION
Do you have any health problems or a medical condition that may affect your ability to perform the requirements of the position as specified above? If so please provide details:
Have you ever had any worker's compensation claims ?
If Yes, was rehabilitation provided? (Give details)
Insurance Company
Employer
Injury 1)
How long off work?
When?
Injury 2)
How long off work?
When?
"s79 of the Workers Compensation and Injury Management Act 1981"
Where it is proved that the worker has, at the time of seeking or entering employment in respect of which he/she claims compensation for an injury, willfully and falsely represented himself as not having previously suffered from the injury an arbitrator may in the arbitrator's discretion refuse to award compensation which otherwise would be payable.
REFEREE LIST
Please list below three referees whom we can contact regarding your suitability for the position:
1)
Employer
Supervisor
Address
Phone
Phone (After hours)
2)
Employer
Supervisor
Address
Phone
Phone (After hours)
3)
Employer
Supervisor
Address
Phone
Phone (After hours)
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