Application Form

Fields marked * are required

Position Applied for :
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 "Green/Blue card"?
Expiry
Number
A COPY OF YOUR CURRENT CARD WILL BE REQUIRED BEFORE COMMENCEMENT DATE
Do you hold a "First Aid" Certificate?
Expiry
EDUCATION
EDUCATION INSTITUTION STANDARD ATTAINED YEAR
Secondary
Apprenticeship
Tertiary
Certificates/Diplomas
BRIEF LIST OF EQUIPMENT WORKED ON
LIST 5 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)
4)
5)
NAMES AND ADDRESSES OF THREE WORK REFEREES FROM WHOM CONFIDENTIAL REPORTS MAY BE OBTAINED
1)
Employer
Supervisor
Address
Phone
Phone (After hours)
2)
Employer
Supervisor
Address
Phone
Phone (After hours)
3)
Employer
Supervisor
Address
Phone
Phone (After hours)
PERSONAL HISTORY
PLEASE ANSWER ALL QUESTIONS AND COMPLETE ALL BOXES
Have you ever had or do you have? (please tick for YES, leave blank for NO)
Rheumatic Fever Epilepsy Convulsion or Fits
Pneumonia Bronchitis Heart Disease
Pleurisy Persistent Diarrhea Persistent Indigestion
Asthma Jaundice or Hepatitis Kidney Or Bladder Trouble
Nervous Trouble or Breakdown Hay Fever Dermatitis
Sinusitis Tubercolosis Gout
Hernia HIV Diabetes
Colour Blindness Bee Stings    
LIST 5 PREVIOUS EMPLOYERS (Including current position and notice period required)
1) Do you now or have you ever suffered a back injury?
If so,specify
2) Deafness or discharge from ears?
If so,specify
3) Impairment Of Vision?
If so,specify
4) Do you wear Prescription glasses or contact lenses?
If so,specify
5) Any other illness?
If so,specify
6) Any surgical operations?
If so,specify
7) Any broken bones or other serious personal injury?
If so,specify
8) Any X-rays or medical investigations?
If so,specify
9) Have you in the last 5 years taken, or are you now taking any stimulants, sedatives, medication or drugs including narcotic drugs?
10) 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?
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Phone: (08) 6436 1111

Fax: (08) 9367 2034
admin@landscapedevelopment.com.au