Application for Employment

Surname:
Given Names:
Address:
Phone:
Mobile:
Email address:
Date of Birth:
Country of birth:
Language spoken:
Are you currently employed:
Martial Status:
No. of children:
Physical disabilities and health:
   

Emergency contact details

   
Name:
Address:
Phone:
Education/Qualifications:
Special Training and Skills:
   

Previous Employment

 
Last employer Duties Period/ reason for leaving
 

Health Questionnaire

Do you suffer from or have you ever suffered from any of the following;

 
Heart trouble Yes No 
High Blood pressure Yes No 
Shortness of Breath Yes No 
Chest Pain Yes No 
Asthma, Bronchitis or chest trouble Yes No 
Dizzy spells or blackouts Yes No 
Fits, fainting, epilepsy Yes No 
Persistent headaches Yes No 
Head injury Yes No 
Nervous or mental illness Yes No 
Skin problems Yes No 
     Rashes Yes No 
     Allergies Yes No 
     Dermatitis Yes No 
     Other Yes No 
Hernia Yes No 
Stomach, liver, gall bladder problems Yes No 
Diabetes Yes No 
Hepatitis Yes No 
Allergies Yes No 
   

Have you ever had?

 
   
Broken Bones
Dislocations
Muscle strains
Tendon or cartilage trouble
Wrist or hand problems
Back pain
Neck pain
 

Is there any reason why you cannot wear?

 
Safety boots
Hearing protection
   

Have you ever had a problem with?

   
Hearing
Ringing in ears
Do you wear? Glasses:
Contacts:
Doctors Name:
Contact Number
 
Are you currently taking any long term medications?    
 
Medication name Treating
Have you ever had a work related injury or illness or workers compensation claim?  Yes No
If yes, please give details:
Are you willing to work in a “Smoke free” environment?  Yes No
Have you ever been charged with a criminal offence?  Yes No
If yes, please give details:
Are you able to work in high places such as multi storey buildings/pole work?  Yes No
Are you able to work overtime?  Yes No

The company reserves the right to terminate employment if false misleading information is submitted.

Signature of applicant
Date
 
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