APPLICATION FOR EMPLOYMENT
Application for Employment
Section A – Position Details
A1: POSITION DETAILS
WHICH POSITION ARE YOU APPLYING FOR?
JOB REFERENCE NUMBER?
EARLIEST DATE YOU CAN START?
Section B – Personal Information
A2: YOUR NAMES AND DATE OF BIRTH
GIVEN NAMES
SURNAME
PREFERRED GIVEN NAME(S) [IF DIFFERENT]
TITLE [MR, MRS, MS, MISS]
PREFERRED SURNAME [IF DIFFERENT]
DATE OF BIRTH
.
A3: PHYSICAL ADDRESS
STREET NUMBER / NAME
SUBURB / TOWN
STATE
POSTCODE
COUNTRY [IF NOT AUSTRALIA]
POSTCODE
COUNTRY [IF DIFFERENT]
.
A4: POSTAL ADDRESS [IF DIFFERENT TO PHYSICAL ADDRESS]
POST OFFICE BOX OR STREET NUMBER / NAME
SUBURB / TOWN
STATE
.
A5: OTHER CONTACT DETAILS
MOBILE NUMBER
WORK NUMBER
HOME PHONE NUMBER
WHICH NUMBER DO YOU PREFER US TO USE?
EMAIL ADDRESS (PRIMARY)
EMAIL ADDRESS (SECONDARY)
.
A6: LANGUAGE AND NATIONALITY
LANGUAGES SPOKEN [OTHER THAN ENGLISH]
ARE YOU AN AUSTRALIAN CITIZEN OR PERMANENT RESIDENT?
Yes
VISA TYPE / CLASS
WORK CONDITIONS
[If “Yes” skip remaining Nationality questions]
ISSUE DATE
EXPIRY DATE
No
COUNTRY
.
A7: MOTOR VEHICLE DRIVING LICENCE
DO YOU HAVE A CURRENT AUSTRALIAN DRIVING LICENCE?
Yes
EXPIRY DATE
No
LICENCE NUMBER
STATE OF ISSUE
[If “No” skip remaining driving questions]
CLASS
TYPE
CONDITIONS
Manual
Auto
.
HUMAN RESOURCE MANAGEMENT
HRM-023
PAGE: 1
APPLICATION FOR EMPLOYMENT
A8: USE OF PRIVATE MOTOR VEHICLE (PMV) FOR WORK PURPOSES
DO YOU HAVE A VEHICLE YOU ARE PREPARED TO USE FOR WORK PURPOSES (ON RECEIPT OF MOTOR VEHICLE
ALLOWANCE?
Yes
No
IS VEHICLE COMPREHENSIVELY INSURED?
[If “No” skip remaining PMV questions]
Yes
No
HAVE YOU EVER BEEN DISQUALIFIED FROM DRIVING?
Yes
[If “Yes” please outline circumstances below]
No
DISQUALIFICATION CIRCUMSTANCES
.
A9: PRIOR EMPLOYMENT WITH ROCKY BAY
HAVE YOU EVER BEEN EMPLOYED BY ROCKY BAY PRIOR TO THIS APPLICATION?
Yes
No
MOST RECENT PERIOD OF EMPLOYMENT
[If “No” skip remaining prior employment questions]
From
To
REASON FOR LEAVING EMPLOYMENT AT ROCKY BAY
REASON FOR RETURNING TO EMPLOYMENT AT ROCKY BAY
.
A10: LANGUAGE OR LEARNING ASSISTANCE
WILL YOU REQUIRE ASSISTANCE WITH LEARNING, [I.E. READING, WRITING, WORKING WITH
NUMBERS]
Yes
[If “Yes” describe assistance required >>
LEARNING ASSISTANCE REQUIRED
No
.
A11: TERTIARY EDUCATION HISTORY
DO YOU HAVE ANY COMPLETE OR PARTIAL TERTIARY EDUCATION HISTORY?
Yes
[List additional qualifications at the end of this form]
NAME OF QUALIFICATION
COMPLETE
No
[If “No” skip the remainder of this section]
YEAR COMMENCED
Yes
No
Yes
No
Yes
No
Yes
No
YEAR COMPLETED
NAME OF INSTITUTION
.
A12: OTHER EDUCATION HISTORY
DO YOU HAVE ANY OTHER EDUCATIONAL OR INDUSTRY QUALIFICATIONS OR SKILLS HISTORY?
Yes
[List additional skills or qualifications at the end of this form]
NAME OF QUALIFICATION OR SKILL
HUMAN RESOURCE MANAGEMENT
COMPLETE
No
YEAR COMMENCED
Yes
No
Yes
No
Yes
No
Yes
No
HRM-023
[If “No” skip the remainder of this section]
YEAR COMPLETED
NAME OF INSTITUTION
PAGE: 2
APPLICATION FOR EMPLOYMENT
Section C – Health
IMPORTANT NOTE
Disclosure of a medical condition or restriction does not necessarily exclude an applicant from employment. As part of our
selection process Rocky Bay reserves the right to get independent confirmation that candidates are able to perform the tasks
associated with the role. We may ask candidates to undertake a function test for this purpose and, if we do, the cost of the
examination will be met by Rocky Bay.
Please tick YES or NO to every question. You should answer YES if you have ever suffered injury to the relevant area regardless
how long ago it happened. If you answer YES please provide full details in the space provided
.
C1: PERSONAL HEALTH HISTORY
INFECTIOUS DISEASES: HAVE YOU HAD ANY OF THE FOLLOWING INFECTIOUS DISEASES? [CHECK BOXES AS APPROPRIATE]
German Measles
Measles
Chicken Pox
Hepatitis A
Hepatitis B
Hepatitis C
.
C2: PERSONAL HEALTH HISTORY
IMMUNISATIONS: DISEASES: HAVE YOU HAD ANY OF THE FOLLOWING INFECTIOUS DISEASES? [CHECK BOXES AS APPROPRIATE]
Measles
Date:
Influenza
Date:
Hepatitis A and B
Date:
Pneumonia
Date:
Chicken Pox
Date:
MMR (Measles, Mumps, Rubella
Date:
.
C3: PERSONAL HEALTH HISTORY
QUESTION
RESPONSE
DETAILS [IF YOU CHECKED “YES”]
Do you have any disability, illness or injury that might affect
your performance of the role applied for, or necessitate Rocky
Bay modifying your work environment (i.e. ramp, etc)?
Yes
No
Are you allergic to or otherwise react to any antibiotic,
medicines, drugs, insect bites, food or anything else?
Yes
No
Do you or have you had any medical or health related condition
that may be affected as a result of being exposed to
medications, detergents, cleaning solutions and pesticides (e.g.
respiratory conditions such as asthma, dermatitis or eczema,
allergenic reactions, etc)?
Yes
No
Have you or are you receiving treatment for an injury, illness or
side effect as a result of being exposed to chemical or toxic
substances or use of personal protective equipment (e.g.
gloves)?
Yes
No
Have you ever lodged a Worker’s Compensation claim with an
employer?
Yes
No
.
C4: GENERAL BACKGROUND INFORMATION
QUESTION
RESPONSE
Are you currently receiving medical treatment for any illness or
condition?
Yes
No
Are you currently taking any medications including inhalers?
Yes
No
Have you ever had an X-ray or scan of your neck and/or back?
Yes
No
Have you ever had a chest X-ray? If so, when and where?
Yes
No
Have you ever spent time in hospital as an in-patient?
Yes
No
Have you ever had an injury or disease resulting from work?
Yes
No
Have you recently required treatment from a chiropractor or
Yes
No
HUMAN RESOURCE MANAGEMENT
HRM-023
DETAILS [IF YOU CHECKED “YES”]
PAGE: 3
APPLICATION FOR EMPLOYMENT
C4: GENERAL BACKGROUND INFORMATION
physiotherapist?
Are you able to wear personal protective equipment without
irritation or experiencing problems of any kind? (eg gloves,
safety boots, ear muffs/plugs, helmet or safety glasses)
Yes
No
Over the last few years, have you lost time from work because
of any illness and/or injury?
Yes
No
Have you had exposure to any toxic substances or
environmental hazards?
Yes
No
Have you ever been a patient or worked in a health facility
outside WA in the past 12 months? If yes, specify where.
Yes
No
Do you suffer or have you ever suffered from repetitive strain
injury?
Yes
No
Are you currently pregnant? If so, what is your due date?
Yes
No
Have you been involved in Motor Vehicle Accident? If so,
when?
Yes
No
Do you have any physical disability?
Yes
No
Is there any history of serious illness or medical conditions in
your immediate family?
Yes
No
Have you lost or gained weight over the past year? If so, how
much?
Yes
No
…
C5: MEDICAL CONDITION QUESTIONS
HAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING CONDITIONS?
Defect in sight of either eye
Yes
No
Sciatica, Back pain, back injury
Yes
No
Diabetes or predisposition to diabetes
Yes
No
Skin problems eg Dermatitis, Eczema
Yes
No
Defect in hearing
Yes
No
Sinus trouble
Yes
No
Vertigo (fear of heights)
Yes
No
Earache or discharging ears
Yes
No
Claustrophobia
Yes
No
Hernia/rupture
Yes
No
Irregular heartbeats, palpitations
Yes
No
Rheumatic Fever
Yes
No
Heart trouble, angina, chest pain
Yes
No
Hay Fever/Allergies of any kind
Yes
No
Shortness of breath
Yes
No
Hepatitis/Jaundice
Yes
No
High blood pressure
Yes
No
Stomach or duodenal ulcers
Yes
No
Wheezing/asthma
Yes
No
Gall/kidney/bladder problems
Yes
No
Tuberculosis or Pleurisy
Yes
No
Colour blindness
Yes
No
Depression
Yes
No
Passing or vomiting blood
Yes
No
Anxiety, panic attacks, insomnia
Yes
No
Goitre or thyroid problems
Yes
No
Mental illness
Yes
No
Cancer or tumour of any kind
Yes
No
Swollen or painful joints
Yes
No
Neck pain and/or injury
Yes
No
Broken or fractured bones, dislocations
Yes
No
Fainting Spells, blackouts, loss of
consciousness
Yes
No
Rheumatics, arthritis
Yes
No
Head injury of concussion
Yes
No
Persistent headaches or migraines
Yes
No
Deep Vein Thrombosis
Yes
No
Epilepsy/Fits
Yes
No
Other joint injuries or conditions
Yes
No
HUMAN RESOURCE MANAGEMENT
HRM-023
PAGE: 4
APPLICATION FOR EMPLOYMENT
C5: MEDICAL CONDITION QUESTIONS
Ankle or Knee trouble or injury
Yes
No
Foot trouble or injury
Yes
No
Wrist/elbow trouble or injury
Yes
No
Severe injury or operation
Yes
No
Tendency to bruise or bleed excessively
Yes
No
Spinal problems including whiplash
Yes
No
Shoulder pain and/or injury
Yes
No
Yes
No
ENTER ANY COMMENTS FOR ANY CONDITIONS EXPERIENCED ABOVE
.
C6: MANUAL HANDLING
DO YOU HAVE DIFFICULTY WITH ANY OF THE FOLLOWING?
Bending down, kneeling, crouching
Yes
No
Working at heights
Yes
No
Lifting heavy objects
Yes
No
Chronic fatigue
Yes
No
Walking on uneven ground or surfaces
Yes
No
Standing for extended periods of time
Yes
No
Lowering, pushing or pulling heavy objects
Yes
No
Moving, holding or restraining any object
Yes
No
Going up and down stairs or ladders
Yes
No
Crouching/bending/kneeling
Yes
No
Sitting for extended periods of time
Yes
No
Carrying heavy objects
Yes
No
Do you suffer from any medical or health related conditions that may be affected by physical or strenuous work
(e.g. tasks such as those stated above)?
Yes
No
Have you ever been treated for an injury as a result of or while attempting to perform any of the above stated
tasks?
Yes
No
IF YOU CHECKED “YES” TO EITHER OF THE LAST TWO QUESTIONS, PROVIDE FURTHER DETAILS BELOW
Dates:
Nature of Injury / Medical Condition
What occurred
Treatment Detail
Length of Time Off Work
DETAILS OF ANY OTHER PAST OR PRESENT CONDITION NOT PREVIOUSLY MENTIONED WHICH MAY IMPACT ON YOUR ABILITY TO SAFELY PERFORM THE DUTIES THAT
WILL BE REQUIRED OF YOU IN THE POSITION YOU ARE APPLYING FOR?
…
C7: HEALTH HABITS AND PERSONAL SAFETY
QUESTION
RESPONSE
Do you smoke or have you ever smoked?
Yes
No
If “Yes”, how many per day?
Do you exercise regularly?
Yes
No
If “Yes”, how often per week and type
Do you take illicit drugs of any kind?
Yes
No
If “Yes”, provide details
Do you drink alcohol?
Yes
No
If “Yes”, average number of standard drinks per week:
HUMAN RESOURCE MANAGEMENT
DETAILS [IF YOU CHECKED “YES”]
HRM-023
PAGE: 5
APPLICATION FOR EMPLOYMENT
Section D – Availability
IMPORTANT NOTE
Complete this section ONLY if you are applying for a position as a Disability Support Worker, Nurse, Monitoring & Support Officer
or other shift position
…
D1: SHIFT AVAILABILITY
WHAT SHIFTS ARE YOU PREPARED TO WORK?
RESPONSE
Work night duty
Regularly
Occasionally
Rarely
Not at all
Not applicable
Work shifts
Regularly
Occasionally
Rarely
Not at all
Not applicable
Work flexible hours
Regularly
Occasionally
Rarely
Not at all
Not applicable
Work on public holidays
Regularly
Occasionally
Rarely
Not at all
Not applicable
…
D2: WORKING HOURS
11 pm
10 pm
9 pm
8 pm
7 pm
6 pm
5 pm
4 pm
3 pm
2 pm
1 pm
12 noon
11 am
10 am
9 am
8 am
7 am
6 am
5 am
4 am
3 am
2 am
Day
1 am
Time From
12 midnight
PLEASE INDICATE BY INSERTING AN “X” IN EACH SQUARE BELOW, CORRESPONDING TO THE HOURS YOU WOULD NORMALLY BE ABLE TO WORK ON A GIVEN WEEK.
Example
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Public Holidays
HUMAN RESOURCE MANAGEMENT
HRM-023
PAGE: 6
APPLICATION FOR EMPLOYMENT
Section E – Applicant Declaration
IMPORTANT NOTE
PLEASE read the following declaration carefully before submitting this application.
.
DECLARATION:
PLEASE READ AND COMPLETE THE FOLLOWING DECLARATION
I [Type your name here]
acknowledge that under the terms of Section 79 of the “Workers’ Compensation and Injury Management Act 1981”,
should a worker, at the time of seeking or entering employment, wilfully and falsely represent himself/herself as not
having previously suffered from an injury and subsequently claims compensation for that injury, the insurance company
may refuse to award compensation which would otherwise be payable.
Under the Privacy Amendment (Private Sector) Act 2000, I consent to Rocky Bay retaining the information stated herein
on file for possible future employment purposes.
I consent to any reference checks which may be necessary to support this application. I understand that Rocky Bay
reserves the right to independently verify my Visa, drivers licence (including State Traffic Certificate with certified copy
of traffic infringement and demerit points), Working with Children and Police Clearance details, and to access details of
any convictions that may be ‘spent’ (removed from a person’s public viewable policy record). I consent to Rocky Bay
doing so.
I certify that my answer to each of the above questions is true and that this information is correct. I understand that any
misrepresentation of facts in this application could be cause for instant termination if I am employed by Rocky Bay.
IF HANDING IN THIS APPLICATION FOR EMPLOYMENT FORM IN A PAPER OR
OTHER PHYSICAL FORM, SIGN HERE TO INDICATE THAT YOU HAVE READ THIS
FORM, FILLED IT IN COMPLETELY AND THAT YOU CERTIFY THE ABOVE.
IF SUBMITTING THIS APPLICATION FOR EMPLOYMENT FORM ELECTRONICALLY,
PLACE AN ‘X’ IN THE BOX BELOW TO INDICATE THAT YOU HAVE READ THIS FORM
AND FILLED IT IN COMPLETELY AND THAT YOU CERTIFY THE ABOVE.
OR
DATE
DATE
E1: RECRUITMENT SOURCE
WHERE DID YOU SEE THIS VACANCY ADVERTISED?
Rocky Bay website
SEEK website
Word of Mouth
Other Source
(specify
West Australian Newspaper
)
Other Newspaper
(specify
)
.
E2: SUBMISSION INSTRUCTIONS
YOUR APPLICATION SHOULD INCLUDE:

This form (completed)

Your resume (providing information about your employment history, qualifications/skills and referees)

A document matching your skills/experience against the selection criteria for the role
SUBMIT YOUR APPLICATION TO:
Email:
recruitment@rockybay.org.au
Fax:
(08) 9383 1230
Post:
Human Resources Team, PO Box 53, Mosman Park, WA 6912
Personal Delivery:
Human Resources Team, 60 McCabe Street, Mosman Park, Western Australia
HUMAN RESOURCE MANAGEMENT
HRM-023
PAGE: 7