Position Applied for
Permanent Casual Other
 
Electrical License (if applicable)  
Type
Number
   
Site or Location of Work you are applying for (if specific)
 
Available to commence work (date)
   

Applicant Detail
Surname
Given Name(s)
Address

Contact Phone Number(s)
Home
Mobile
Fax
Email
Date of Birth
Drivers Lic. No
   

Next of Kin or Emergency Contact Person
Surname
Given Name
Relationship
Address
Contact Number 1
Contact Number 2
   

Occupational History (brief)
  Date(s) Employer Contact Peron Phone No Mobile No
1
2
3
Superannuation provider
Membership / account number
Long Service Leave No
MERT No
OH&S Construction Induction Certificate No. (green card)
   
Please list other licences or certificates you may have (eg. First aid, forklift, etc)
   
Are you prepared to work at remote or distant locations (interstate, etc) Yes      No
Provide details of existing site induction passes (including expiry dates)
   
Are you prepared to attend a medical (if requested) prior to employment commencement Yes      No
   
Do you have any existing illnesses or disabilities Yes      No
If YES please detail
   
Have you ever made a workers compensation claim Yes      No
If YES please detail
   
By clicking the submit button, I declare that this document is Complete, True & Accurate to the best of my knowledge. I am prepared to supply a copy of all relevant certificate(s) and licence(s) as listed above at the point / time of interview.