Application for Vacancy Form
Vacancy Details
Position title:
Personal Details
Title:
 Mr
 Miss
 Mrs
 Ms
Surname:
Given name:
Address:
Contact number:
Email:
Residency/Visa Information
Are you an Australian Permanent Resident?
 No
 Yes
Are you currently subject to any visa restrictions?
 No
 Yes
Please provide visa details:
(Please note: this information is ESSENTIAL in order for your application to progress)
Qualifications
Certificate/Registration name & number
Expiry date:
Drivers Licence
Do you hold a current drivers licence that legally allows you to drive in WA:
 No
 Yes
Are you on any provisional plates (e.g. ‘L’ or ‘P’ Plates)
 No
 Yes
What class of drivers licence do you hold:
 Auto
 Manual
Supplementary details provided below will not be a barrier to employment but will assist the Human Resource Department in
assessing appropriate placements.
Workers Compensation
Section 79 of the Workers’ Compensation and Rehabilitation Act 1981 states “Where it is probed 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 himself/herself as not having previously suffered from the disability a dispute resolution body may in its discretion
refuse to award compensation which otherwise would be payable”.
Health Information
Are you aware of any previous accident or existing disability which would restrict your ability to
perform the duties of this position?
 No
 Yes
If “Yes”, please give details:
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Application for Vacancy Form
Have you been an inpatient/employee in a healthcare facility outside of Western Australia in the
previous 12 months (including overseas)?
Convictions
Have you ever been convicted of any criminal or traffic convictions for any offences from any court?
 No
 Yes
 No
 Yes
If “Yes”, please give details:
Previous Employment (most recent first)
Company name
Start date
End date
Position held
Reason for leaving
Referees
Please provide the details of two referees. At least one of whom must be your current or a recent supervisor.
Referee 1
Referee 2
Name:
Company:
Position title:
Contact numbers:
Email:
Successful Applicants
You will be required to provide written consent and 100 points of identification to enable Ability Centre to obtain a compulsory
National Police Certificate on your behalf.
Depending on the role you may require to provide:
 A Working with Children Check
 Relevant State Traffic Certificate
 A medical assessment to assess your physical capabilities to undertake the role.
Employment Checklist
 Application form completed
 Selection criteria address and attached (if in advert)
 Copy of Visa details attached (if applicable)
How did you become aware of this vacancy?
 Ability Centre web page
 West Australian
 Current staff member, please state name:
Have you worked with Ability Centre in the past?
 Covering letter attached
 Current resume (CV) attached
 SEEK
 Community News
 Other, please explain:
 No
 Yes
If “Yes”, please give details:
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Application for Vacancy Form
Declaration
I declare the above statements to be true in all respects. I acknowledge that any statement, which is found to be false or
deliberately misleading, will make me, if employed, liable for dismissal.
I consent to Ability Centre disclosing the information contained in this application, to those individuals and organisations deemed
necessary to complete inquiries into the accuracy of the information contained in this application, and the suitability for me for
this position.
Signature:
Delivery Instructions
Post
Private and Confidential
Human Resource Officer
Ability Centre
PO Box 61
MT LAWLEY WA 6929
Application for Vacancy Form
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Date:
Email
jobs@abilitycentre.com.au
Hand in
Private and Confidential
Human Resource Officer
Ability Centre
106 Bradford Street
MT LAWLEY WA 6929
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Pre-Placement Health Questionnaire Form
Pre-Placement Health Questionnaire
Health assessments are an integral part of the employment process to ensure that an applicant for employment is able to
perform the inherent requirements of the position under consideration. You may be contacted if there are any issues in the
questionnaire that require clarification.
Past and Present Medical Information
 No
Do you have any specific health issues that will impact on your ability to perform your job?
 Yes
Details:
 Excellent
How would you describe your general health?
 Very Good
 Usually Good
 Just OK
Details:
Have you had any significant illness. admission to hospital or surgical procedure performed in the
last five (5) years (excluding normal pregnancy and delivery)?
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
Details:
Are you currently being treated by a doctor for any physical or psychological condition?
Details:
Are you currently taking any prescribed medication?
Details:
Do you have any know allergies:
Details:
Have you ever been injured, suffered from a work related illness or submitted a Workers
Compensation or Motor Vehicle Insurance Trust (MVIT) claim
Details:
Do you have or have you had any of the following?
Tetanus
 No
 Yes
Have you been immunised?
 No
 Yes
Hepatitis B
 No
 Yes
Have you been immunised?
 No
 Yes
High blood pressure
 No
 Yes
Arthritis
 No
 Yes
Heart Disease
 No
 Yes
Migraines
 No
 Yes
Asthma/Lung disease
 No
 Yes
Epilepsy/Fits/Convulsions
 No
 Yes
 No
 Yes
Nervous or Mental Illness
 No
 Yes
Skin problems
(including Depression)
If you answered yes to any of the above please provide further details:
Declaration
I declare that the answers to all questions are correct and that I have not withheld any information regarding my past or present
health and I accept that if I am employed and it is subsequently found that I have wilfully misstated any significant information
herein, I will be liable for dismissal.
I give permission to the Human Resources Department or a medical practitioner nominated by Ability Centre to seek and obtain
any other relevant information from any available source which may be required to assess my present health status.
Signature:
Date:
Full name in BLCCK LETTERS:
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