EMPLOYEE
APPLICATION FORM
Timberden Plant Hire
PO Box 1311
TOODYAY WA 6566
Telephone: 9574 4426
Facsimile: 9574 4253
email: ian@timberden.com.au
Timberden Plant Hire
APPLICATION
FIRST NAME
LAST NAME
PREFERRED NAME
DATE
POSITION APPLYING FOR
FULL TIME or CASUAL
IMPORTANT- PRIVACY STATEMENT



Information requested within this application is required for the purpose of considering your suitability for the position for
which you are applying.
Should your application be successful this information will be kept on your personal file and an electronic database available
only to yourself, your Manager(s) and Human Resource Personnel. An exception will be made only where an emergency exists
and contact details are required.
Please fill in this form yourself and attach copies of any references, qualifications or other achievements which support your
application.
PERSONAL INFORMATION
ADDRESS
POSTAL ADDRESS
HOME Phone Number
MOBILE Number
EMAIL ADDRESS
DRIVERS LICENCE Number
DRIVERS LICENCE ISSUED
EXPIRY DATE
WA, SA, VIC, ACT, NSW, QLD, NT
CATEGORIES
DATE of BIRTH
MARITAL STATUS
NEXT of KIN
NAME
ADDRESS
HOME Phone Number
MOBILE Phone Number
RELATIONSHIP
ELIGIBILITY TO WORK IN AUSTRALIA
ARE YOU AN AUSTRALIAN RESIDENT
YES
NO
DO YOU HAVE A CURRENT WORK PERMIT
YES
NO
Jul 2011
Page 1 of 6
Timberden Plant Hire – Form 401 Rev 4
EMPLOYEE
APPLICATION FORM
Timberden Plant Hire
PO Box 1311
TOODYAY WA 6566
Telephone: 9574 4426
Facsimile: 9574 4253
email: ian@timberden.com.au
Timberden Plant Hire
TRAINING & EDUCATION
LAST SCHOOL ATTENDED
HIGHEST YEAR REACHED
CURRENT STUDY / TRAINING
OTHER WORK QUALIFICATIONS
OTHER WORK SKILLS
DO YOU HAVE EXPERIENCE, TRAINING or CERTIFICATION IN ANY OF THE FOLLOWING?
SUBJECT
SOME EXPERIENCE
ALOT of EXPERIENCE
TICKET/CARD NUMBER
EXPIRY DATE
BLUE / WHITE CARD
FIRST AID
QUICK CUT
DUMPY / LASER LEVEL
TRAFFIC MANAGEMENT
DOZER OPERATOR
FORKLIFT OPERATOR
DOGGING CERTIFICATE
EXCAVATOR OPERATOR
LOADER OPERATOR
SUPERVISORY SKILLS
GRADER OPERATOR
ROLLER DRIVER
CRANE TICKET
HEALTH, SAFETY, ENVIRO
TRACTOR OPERATOR
CURRENT HEAVY VEHICLE
MEDICAL
CURRENT HEAVY VEHICLE
FATIGUE
OTHER:
Jul 2011
Page 2 of 6
Timberden Plant Hire – Form 401 Rev 4
EMPLOYEE
APPLICATION FORM
Timberden Plant Hire
PO Box 1311
TOODYAY WA 6566
Telephone: 9574 4426
Facsimile: 9574 4253
email: ian@timberden.com.au
Timberden Plant Hire
EMPLOYMENT HISTORY
EMPLOYER NAME
POSITION TITLE
EMPLOYED FROM
EMPLOYED TO
DUTIES & TASKS
REASON for LEAVING
EMPLOYER NAME
POSITION TITLE
EMPLOYED FROM
EMPLOYED TO
DUTIES & TASKS
REASON for LEAVING
EMPLOYER NAME
POSITION TITLE
EMPLOYED FROM
EMPLOYED TO
DUTIES & TASKS
REASON for LEAVING
REFEREES
EMPLOYER NAME
POSITION TITLE
REFEREE NAME
PHONE No.
EMPLOYER NAME
POSITION TITLE
REFEREE NAME
PHONE No.
EMPLOYER NAME
POSITION TITLE
REFEREE NAME
PHONE No.
I consent to Timberden Plant Hire seeking verbal or written information on a confidential basis about me from representatives of my
previous employers and/or referees and authorise the information sought to be released, by those contacted, to Timberden Plant
Hire for the purpose of ascertaining my suitability for the position I am applying for.
If you consent to the above SIGN:
DATE:
Jul 2011
Page 3 of 6
Timberden Plant Hire – Form 401 Rev 4
EMPLOYEE
APPLICATION FORM
Timberden Plant Hire
PO Box 1311
TOODYAY WA 6566
Telephone: 9574 4426
Facsimile: 9574 4253
email: ian@timberden.com.au
Timberden Plant Hire
OTHER INFORMATION
WHEN CAN YOU START WORK
WAGE EXPECTATION
CAREER GOALS
CAREER HIGHLIGHTS
HOBBIES & INTERESTS
MEDICAL HISTORY
Have you ever had a Workers Compensation Claim? If YES, please give details:
Date of Claim:
Nature of Injury:
Employer Name:
Time away from Work:
Was a FINAL medical Certificate issued from the Doctor:
Are there ANY ongoing disability(s) relating to the claim:
FITNESS for WORK
YES
NO
Are you being treated by any Doctor for any illness or taking any medications for a medical condition that
Timberden Plant Hire need to be aware of in the case of an emergency?
Are you required to take any medication that may affect your performance at work or affect your attendance?
Are you willing to take a pre-employment medical and which may include a drug & alcohol screening?
Are you willing to take part in any Fit for Work programs which may include random drug & alcohol screenings?
Have you any current medical or surgical conditions that may affect your ability to carry out the position you have
applied for?
Do you have any Medical Condition(s) that need to be monitored regularly, or medical issues your employer needs
to be made aware of to ensure your safety and fitness for work?
Have you had any time off work (more than 3 days at one time) in the last year?
Have you ever had a serious back, neck, shoulder, arm, knee or joints problem?
Is there any reason why you cannot wear safety clothing i.e. Hard hat, vest, boots, gloves, ear plugs?
Have you had a Tetanus injection or Tetanus booster in the last ten years?
Are you affected by “Working at Heights” or “Confined Spaces” at all?
Do you suffer from any of the following ailments or have difficulty with any of the following activities? YES or NO
High Blood Pressure
Visual Impairments
Climbing a Ladder
Lung problems / Asthma
Stomach problems, Ulcers
Lifting or Bending
Tuberculosis
Joint problem, Fractures
Using Hand Tools
Hernia
Hepatitis, Jaundice, Liver
Reading plans & Procedures
Fits, Seizures, Blackouts
Skin disorders
Walking on Rough Ground
Headaches, Migraines
Health effects from dust
Gripping both hands firmly
Jul 2011
Page 4 of 6
Timberden Plant Hire – Form 401 Rev 4
EMPLOYEE
APPLICATION FORM
Timberden Plant Hire
PO Box 1311
TOODYAY WA 6566
Telephone: 9574 4426
Facsimile: 9574 4253
email: ian@timberden.com.au
Timberden Plant Hire
Diabetes
Allergies
Turning your head quickly
Repetitive Strain Injury
Kneeling, Squatting, Crouching
Repetitive hand movements
Arthritis, Rheumatism
Standing for > 2 hours
Repetitive arm movements
Mental, Nervous troubles
Sitting for > 2 hours
Repetitive leg movements
Loss of Hearing
Hearing a conversation
General Manual Handling
Ear Infections, Dizziness
Understanding English
Lifting < or up to 25kgs
If YES please give details.
List of Medications currently Taken.
FITNESS for WORK Continued
Have you had any exposure to the following in your past jobs?
SUBJECT
YES / NO
If YES please give details.
Loud noise, explosions, gunfire
Asbestos
Chemicals
Radiation
Dust
NOTE: Timberden Plant Hire may require applicants to have a health assessment, which may include testing for illicit drugs, prior to
employment being confirmed.
Applicants are advised that Timberden Plant Hire promote a Smoke Free environment and smoking in any Timberden Plant Hire office,
vehicle, plant & equipment or where there is a risk of fire is prohibited.
Jul 2011
Page 5 of 6
Timberden Plant Hire – Form 401 Rev 4
EMPLOYEE
APPLICATION FORM
Timberden Plant Hire
PO Box 1311
TOODYAY WA 6566
Telephone: 9574 4426
Facsimile: 9574 4253
email: ian@timberden.com.au
Timberden Plant Hire
DECLARATION
Section 79 of the Workers Compensation and Rehabilitation 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 a disability, wilfully and falsely represented
themselves as not having previously suffered from a disability, a dispute resolution body may in its discretion refuse to award
compensation which otherwise would be payable.”
I ………………………………................................. declare that to the best of my knowledge the answers in this application are correct. I
understand that if any false or deliberately misleading information is given, or any material fact suppressed, I may not be accepted,
or if I am employed, my employment may be terminated. I also understand that any offer of employment made is conditional on
my obtaining a medical clearance through the Timberden Plant Hire pre-employment medical and I consent and authorise the
Company’s doctor to conduct an appropriate medical assessment, which may include testing for illicit drugs and for the doctor to
forward this information to the Company.
SIGN..............................................................DATE...............................................................
Jul 2011
Page 6 of 6
Timberden Plant Hire – Form 401 Rev 4