Confidential
Job Application Form
Section 1: Applicant Information
Position Advertised
Position applied for
Lifeguard
Position No
PLS1003
Position Status
Close Date
Casual
Friday 18th September 2015
Personal Details
Gender
Title
Female 
Male 
Ms 
Mrs 
Other ………………….
Mr 
Family name
Given name(s)
Home address
Postcode
Postal address
Postcode
(if different to above)
Phone
Mobile
Home (
)
Email
Qualifications – do you hold:
Apply First Aid?
 No
 Yes
Expiry Date:
Pool Lifeguard Certificate?
 No
 Yes
Expiry Date:
Working with Children Check?
 No
 Yes
Expiry Date:
Drivers Licence?
 No
 Yes
Class:
Do you have previous experience?
 No
 Yes
How many years?
Experience
Work Related Referees
Please provide names and contact details for a minimum of two Referees who can testify to your skills, experience, qualifications
and aptitude in relation to the position you have applied for.
Referee 1 Name
Position
Relationship
 Employer/Supervisor
 Colleague
 Customer
 Other: ______________________
Contact Number
1
2
Contact Email
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Referee 2 Name
Position
Relationship
 Employer/Supervisor
 Colleague
 Customer
 Other: ______________________
Contact Number
1
2
Contact Email
Requirements For Appointment
You can only be appointed to a permanent position at Snowy Works and Services if you:



Are an Australian citizen or have the status of permanent resident in Australia
Give us proof of identity and any other documents such as Certificates and Licences requested
Are deemed fit through medical and functional assessment to undertake the duties and requirements of the position
Please answer the following questions:
Is there any mental, physical or medical condition that would prevent you from fulfilling the
requirements of the position?
Yes
No
(please circle)
Do you have any outstanding charges against your Drivers Licence that would cause it to
be disqualified either now or in the future?
Yes
No
(please circle)
Any statement on your application found to be deliberately misleading could make you liable to dismissal if appointed
Signature
Date
Section 2: Fitness for Work
Please complete the following declaration relating to your fitness for work:
IMMUNISATION HISTORY
IMMUNISATION
PREVIOUSLY IMMUNISED
DATE LAST IMMUNISED
HEPATITIS A
 Yes  No
/
/
HEPATITIS B
 Yes  No
/
/
TETANUS
 Yes  No
/
/
EMPLOYMENT HISTORY
Please provide details of your last 3 employers, starting with your most recent employment and working back:
YEARS OF
EMPLOYER
EMPLOYMENT
OCCUPATION / TYPE OF INDUSTRY
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SIGNIFICANT INJURY HISTORY
1.
Have you had any significant injuries or conditions that were not work related that
resulted in a permanent disability that may affect your ability to undertake the duties of
this position?
 Yes
 No
If Yes, please provide summary details below (you may be asked to provide further information)
INJURY / CONDITION / DISABILITY
INJURY DATE
1.
2.
3.
4.
WORKERS COMPENSATION HISTORY
1.
Have you had any serious injuries requiring medical attention that were work related
and subject to a workers compensation claim?
 Yes
 No
If Yes, please provide details below (attach a separate page if necessary)
INJURY DATE
1.
/
/
2.
/
/
3.
/
/
INJURY TYPE
EMPLOYER
2.
Have you been given a full medical clearance for any of these injuries?
 Yes
 No
3.
Are you receiving any ongoing treatment for any of these injuries?
 Yes
 No
If you are receiving ongoing treatment or have permanent restrictions please give details:
(attach a separate page, if needed)
Section 79 of the Workers’ Compensation and Assistance Act 1981 gives the Workers’ Compensation Board discretion to
refuse to award compensation which would otherwise be payable, where it is proved that the worker has, at the time of
seeking or entering employment wilfully and falsely represented himself as not having previously suffered from the
disability, the subject of the claim for compensation.
MEDICAL HISTORY
THIS INFORMATION IS USED FOR THE PURPOSES OF ASSISTING MANAGERS TO MAKE AN INFORMED ASSESSMENT OF
SUITABILITY TO MEET THE INHERENT REQUIREMENTS OF THE ADVERTISED POSITION.
Have you ever suffered from or been told that you had any of the following:
COMMENTS
CONDITION/SYMPTOM
RESPONSE
Back Injury / Chronic Back Pain

Yes

No
Arthritis / rheumatism / gout

Yes

No
Carpel tunnel / Tenosynovitis

Yes

No
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(include details of the condition, treatment and any ongoing
management e.g. puffer for asthma, glasses for sight problems)
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COMMENTS
CONDITION/SYMPTOM
RESPONSE
Occupational Overuse Syndrome /
Repetitive Strain Injury

Yes

No
Hand, wrist or elbow injury, pain or
weakness

Yes

No
Neck Injury and/or Recurrent Pain

Yes

No
Knee Injury and/or Recurrent Pain

Yes

No
Shoulder Injury and/or Recurrent Pain

Yes

No
Ankle or Foot Injury and/or Recurrent
Pain

Yes

No
Hernias

Yes

No
Conditions affecting the Lungs or
difficulty breathing (e.g. pleurisy)

Yes

No
Bronchitis

Yes

No
Asthma

Yes

No
Hay fever / Sinus / Other Allergic
Conditions

Yes

No
Tuberculosis

Yes

No
Heart condition / chest pain

Yes

No
Haemophilia

Yes

No
Hepatitis / HIV / Aids

Yes

No
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(include details of the condition, treatment and any ongoing
management e.g. puffer for asthma, glasses for sight problems)
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COMMENTS
CONDITION/SYMPTOM
RESPONSE
Cancer

Yes

No
Epilepsy / fits

Yes

No
Diabetes

Yes

No
Thyroid disorder

Yes

No
Recurrent Headaches / Migraines

Yes

No
Skin complaint (e.g. dermatitis, eczema,
skin cancer)

Yes

No
Ulcers

Yes

No
Severe anxiety, depression or other
mental or nervous disorder

Yes

No
Ear problems / hearing loss

Yes

No
Eye sight problems
(e.g. colour blindness, tunnel vision)

Yes

No
High blood pressure

Yes

No
Kidney or bladder disease

Yes

No
Claustrophobia or acrophobia i.e. fear of
confined spaces or heights

Yes

No
Condition which affects the ability to
wear personal protective equipment
including gloves, boots, ear protection,
sunscreen, long sleeve shirts

Yes

No
(include details of the condition, treatment and any ongoing
management e.g. puffer for asthma, glasses for sight problems)
Other condition which may affect your
capability to meet the full duties of this
position:
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LIFESTYLE
DO YOU SMOKE?
DO YOU REGULARLY DRINK
ALCOHOL?
DO YOU USE NARCOTICS OR
STIMULANTS?
DO YOU EXERCISE REGULARLY?
 Yes
 Heavy
 No
AVERAGE NO. OF SMOKES / DAY =
 Yes
 Heavy
 No
 Yes
 No
 Yes
 No
 Moderate
 Moderate
 Light
 Light
AVERAGE NO. OF DRINKS / DAY =
 Heavy
 Moderate
 Light
AVERAGE AMOUNT / DAY =
 Heavy
 Moderate
 Light
AVERAGE MINUTES / DAY =
APPLICANT DECLARATION




I am not aware of any circumstances regarding my health which may interfere with the satisfactory
discharge of the duties of the position applied for.
I declare that to the best of my knowledge and belief, all the information I have provided is true and correct.
I am aware that false or misleading statements may affect my appointment or continued employment.
I understand that my personal information acquired from this history will be released to appropriate
SnowyWS officers only for the purpose of managing risk to worker health and safety.
I further accept that a condition of my employment with Snowy Works & Services will be to abide by all
safety rules and to wear protective clothing and equipment as prescribed.
Name:
Signature:
Date:
Please Print
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