Registration of Interest
Please read and ensure you understand the following before completing this form.
Complete all sections. Incomplete forms cannot be processed and will lead to you not being considered.
Photocopies of supporting documentation such as tickets, licences, qualifications and passports/birth certificates will be requested when required to support your
application. Your registration cannot be processed until you provide your copies.
Submitting this form is not an offer of employment and does not guarantee employment with Caledonia.
We may contact any of your previous employers shown on this form for the purpose of confirming your employment details and determining your suitability for
employment.
If you are being considered for employment, the information supplied on this form and our confirmation of your work history will be checked for the purpose of
determining your suitability for employment.
If you are offered and accept employment, information will/may be provided to future Project/Site/Clients about your mobilisation, work and demobilisation. (See
further details in the Declaration at the end of this form).
Personal Information
Title
Mr
Mrs
Miss
Dr
Surname
First Name
Preferred Name
Date of Birth (optional)
Prof
/
/
Residential Address
Suburb
State
Country
Postcode
Work Ph
Home Ph:
Mobile Ph
Email
Current Occupation
Are you legally entitled to work in Australia without a visa?
Visa Number
Yes
No
Are you seeking sponsorship?
Issue Date
Expiry Date
Yes
No
/
/
Residency/Citizenship Status
Aboriginal/ Torres Strait Islander
New Zealand Citizen
Australian Citizen
Permanent Resident
Emergency Contact Information 1
This person must be a next of kin who can be contacted in the event of an emergency. This person cannot be your employer.
The address must be their actual home address. A post office box is not acceptable
Last Name
First Name
Relationship
Address
State
Suburb
Home Ph:
State
Post Code
Country
Work Ph:
Postcode
Mobile Ph:
Emergency Contact Information 2 (Optional)
This person must be a next of kin who can be contacted in the event of an emergency. This person cannot be your employer.
The address must be their actual home address. A post office box is not acceptable
Last Name
First Name
Relationship
Address
State
Suburb
State
Home Ph
Work
Ph
Post Code
Country
Postcode
Mobile Ph
Construction/Project Experience
Are you currently employed by the company that
you completing this form for?
Have you ever worked in the Scaffolding
industry?
Yes
No
If YES, for how long?
Years
Months
Yes
No
If YES, for how long?
Years
Months
Have you ever worked on an LNG project?
Yes
No
If YES, for how long?
Years
Months
Have you ever worked in the Construction/Mining
industry?
Yes
No
If YES, for how long?
Years
Months
Have you ever worked in Regional WA or SA
Yes
No
If YES, for how long?
Years
Months
Are you currently completing an Apprenticeship?
Yes
No
If YES what year or your Apprenticeship are you in?
F-126
Page 1 of 10
Year
25/03/2014
Registration of Interest
Position Sought (Please tick only one position you are interested in form the list below)
Abrasive Blaster
Cost Control
High Voltage Cable Joiner
Mobile Plant Operator
Crawler Tractor
HSE Administrator
NDT Technical Assistant
Accounts Assistant
Crawler Loader
HSE Advisor
NDT Technical Officer
Administrator / Clerical
Draftsperson
HSE Manager
NDT Technician
Scaffold Inspector
Administration
Manager
Aggregate Crushing
Plant
Cryogenic Insulation
Applicator
Human Resources
Administrator
Nurse (Registered)
Scaffolder Leading
Hand
Diver
Human Resources Advisor
Operations Manger
Scaffolder
Agitator Truck Driver
Document
Controller
Painter
Scaffolder Trainee
Apprentice – Other
Dogger (Licensed)
Human Resources
Manager
Hydraulic Fitter
Accountant
Auto Electrician
Backhoe Operator
Barge Mechanic
Bitumen Sprayer
Boilermaker
Breakfast Cook
Drillers offsider
Drilling Machine
Operator
Dump Truck
Operator
Electrical –
Apprentice
Electrical Fitter
Electrical Installer
Roller Operator
Scaffolder Superintendent
ScaffolderSupervisor
Paramedic
Scraper Operator
Industrial Relations
Manager
Payroll Assistant
Security Officer
Information Technology
Payroll Advisor
Service Attendant
Inspector
Payroll Manager
Instrument Fitter
Peggy
Sheet Metal
Worker
Instrument Fitter / Electrical
Physiotherapist
Site Administrator
Pile Driver Operator
SPMT Trailer
Operator
Pipe Fitter
Spotter
Instrumentation and Control
Tradesperson
Insulation Applicator (not
cryogenic)
Serviceperson
Bricklayer
Electrical Mechanic
Bricklayer – Apprentice
Electrical Trades
Assistant
Kitchen Hand
Pipelayer / Drainer
Steel Fixer
Bus Driver
Electrician
Labourer
Planner
Steel Fixer Leading Hand
Business
Development
Manager
Cable Joiner
Electrician Leading Hand
Electrician Special
Class
Electronics
Tradesperson
Emergency
Response
Officer
Engineer
Managing Director
Plumber
Supervisor
Manitou Operator
Plumber – Apprentice
Supply Base
Operator
Carpenter
Carpenter – Apprentice
Carpenter – Leading
Hand
Ceiling Fixer
Chef
Cleaner
Compactor/Roller
Operator
Commercial Manager
Commissioning
Concrete Batch Plant
Operator
Concrete
Finisher/Grouter
Concrete Gun or Pump
Operator
Concrete Labourer
Environmental
Advisor
Environmental
Coordinator
Environmental
Engineer
Environmental
Manager
Excavator
Marine Officer
Marine Administration
Marine Australian Seafarers
Traineeship (AST)
Marine Chief Catering
Officer
Pneumatic Tyred Tractor
Operator
Powder Concrete
Finisher Operator
Powder Monkey / Shot
Firer
Procurement Purchasing
Officer
Storeperson
Marine Chief Cook
Project Engineer
Training
Coordinator
Marine Chief Engineer
Project Manager
Truck Driver
Marine Chief Officer
Project Secretary
Extinguisher
Technician
Marine Coxswain
Project Administrator
Final Trim Operator
Marine Master
Quality Control
Fire Sprinkler Fitter
Materials Coordinator
Quarantine
Welder
Foreman
Mechanic
Radiation Safety Officer
Welder Special
Assistant
Forklift Operator
Mechanical Fitter
Refrigeration Mechanic
Welding Inspector
Rigger - Leading Hand
Water Cart
Rigger Advanced
Workplace Trainer
and Assessor
Rigger Intermediate
Yard Supervisor
Construction Manager
General Manager
General Practitioner
Mechanical Tradesperson
Special Class
Mechanical/Metal – Leading
Hand
Mechanical/Metal Trades
Assistant
Contracts Manager
Grader Operator
Metal Trades – Apprentice
Rigger Basic
Cook
Hand Controlled
Roller Operator
Mobile Crane Operator
Rigger in Training
F-126
Surveyors
Assistant Technical
ChainmanServices
Tool and Material
Traffic Controller
Form Worker
Experience in position sought
Surveyor
Project Controls Manager
Concrete Worker –
Leading Hand
Contracts Administrator
Marine Engineer
Years
Vacation /Work
Experience Student
Warehouse /
Storeperson
Warehouse
Supervisor
Months
Page 2 of 10
25/03/2014
Registration of Interest
Do you have a High Risk Work License/Work Safe Certificate?
If YES, select your High Risk level of qualification from the
list below:
If YES, select your High Risk level of qualification from the
list below:
If YES, select your High Risk level of qualification from the
list below:
If YES, select your High Risk level of qualification from the
list below:
If YES, select your High Risk level of qualification from the
list below:
Dogging
Yes
No
Issue Date
/
/
Expiry Date
/
/
Certificate No
Issue Date
/
/
Expiry Date
/
/
Certificate No
Issue Date
/
/
Expiry Date
/
/
Certificate No
Issue Date
/
/
Expiry Date
/
/
Certificate No
Issue Date
/
/
Expiry Date
/
/
Certificate No
Crane
DG – Dogging
CT - Tower Crane Operation
Rigging
CD - Derrick Crane Operation
RB - Basic Rigging
CN - Non-slewing Mobile Crane Operation (greater than 3 Tonne)
RI - Intermediate Rigging
CV - Vehicle-loading Crane Operation (greater than or equal to 10 Tonne)
RA - Advanced Rigging
C2 - Slewing Mobile Crane Operation (up to 20 Tonne)
Scaffolding
C6 - Slewing Mobile Crane Operation (up to 60 Tonne)
SB - Basic Scaffolding
C1 - Slewing Mobile Crane Operation (up to 100 Tonne)
SI - Intermediate Scaffolding
C0 - Slewing Mobile Crane Operation (open/greater than 100 Tonne)
SA - Advanced Scaffolding
CB - Bridge and Gantry Crane Operation
Loadshifting (Forklift)
CP - Portal Boom Crane Operation
LF - Forklift Truck Operation
Pressure Equipment (Boilermaker)
LO - Order-picking Forklift Truck
BB - Basic Boiler Operation
Concrete Placing Boom
BI - Intermediate
PB - Concrete Placing Boom Operation
Boiler Operation
Hoist
BA - Advanced Boiler Operation
HM - Material Hoist Operation (Cantilever Platform)
TO - Turbine Operation
HP - Hoist Operation (Personnel & Materials)
ES - Reciprocating Steam Engine Operation
Other
Elevating Work Platform
Other
WP - Boom-type Elevating Work Platform
Other Tickets, Licenses and or Training: Do you have the following?
Working At Heights
Working at Heights Gap (BHP, Rio
Tinto etc)
Yes
Yes
No
No
Bosiet
Yes
No
Sea Survival
Yes
No
Rio Lock Holders
RIO Personal Isolation
Yes
Yes
No
No
RIO Fire Extinguisher
Yes
No
RIO Iron Ore Essentials
Yes
No
VOC
BHP Billiton WAIO
Safety Leadership for Supervisors
Yes
Yes
No
No
Section 44
Yes
No
Rope Access
Yes
No
Other
Other
F-126
Cert/Ref
Number
Cert/Ref
Number
Cert/Ref
Number
Cert/Ref
Number
Cert/Ref
Number
Cert/Ref
Number
Cert/Ref
Number
Cert/Ref
Number
Cert/Ref
Number
Cert/Ref
Number
Cert/Ref
Number
Cert/Ref
Number
Cert/Ref
Number
Cert/Ref
Number
Page 3 of 10
Expiry Date
Expiry Date
Expiry Date
Expiry Date
Expiry Date
Expiry Date
Expiry Date
Expiry Date
Expiry Date
Expiry Date
Expiry Date
Expiry Date
Expiry Date
Expiry Date
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
State
State
State
State
State
State
State
State
State
State
State
State
State
State
25/03/2014
Registration of Interest
Medical and First Aid Qualifications
Medical Practitioners
Are you a registered Medical Practitioner?
Nursing
Are you a registered Nurse (RN)?
Yes
Are you an Enrolled Nurse (EN)?
First Aid
Are you a Certified First Aider?
If YES, select certificate from list below
Cert/Ref Number
Yes
Yes
No
Yes No
No
Yes
No
Cert/Ref Number
Yes
No
Cert/Ref Number
Expiry Date:
……./……/
Expiry Date
…….
Cert/Ref Number
Emergency First Aid (Introductory First Aid)
Expiry Date
Expiry Date:
……./……/
Expiry Date
…….
/
/
State
/
/
State
/
/
State
/
/
State
Occupational First Aid (WorkSafe Level 3)
Industrial Health Care – ER / Emergency Response (Industrial Ambulance Care)
– St John Ambulance Only
Industrial Health Care – PM / Paramedic
(Industrial Ambulance Care) – St John Ambulance Only
Basic Workplace First Aid (WorkSafe Level 1)
Senior First Aid
Workplace First Aid (WorkSafe Level 2)
Industrial Health Care – OER / Offshore Emergency Response
Remote Area First Aid
Industrial Health Care – OP / Offshore Paramedic
Welding Qualifications
Do you have a welding qualification?
Yes
No
Cert/Ref Number:
If YES, please indicate your current and lapsed codings including the process used and the State of Australia in which you gained certification:
Stick Electrodes (S.M.A.W)
Structural
Expiry Date
/
/
State Certified
Expiry Date
/
/
State Certified
Pipe
Expiry Date
/
/
State Certified
Pipe
Expiry Date
Pipe
Gas Shielded Flux Cored (F.C.A.W)
Structural
Pipe
D Sub Arc Welding (S.A.W)
Structural
D Tig Welding (G.T.A.W)
Structural
/
/
State Certified
Radiation Safety License
Do you have a radiation safety license?
Yes
No
Cert/Ref Number
Expiry Date
/
/
State
/
/
State
Class
Compliance Testing – Fixed Radiation Gauges
Radiography - Industrial
Gauges – Fixed Industrial
X-ray Analysis
Gauges – Logging
Radioactive Ores – Mining and/or Processing
Gauges – Portable Density/Moisture
Other: please specify
WA/SA electrical license?
Yes
No
Cert/Ref Number
Expiry Date
If YES, select the relevant classifications below:
A Grade – Licensed Electrician
C Grade – Apprentice Electrician
Restricted Electrical Worker’s License
Work Area
Units of Competence
Office Equipment
Occupational health and safety procedures
Domestic Equipment
Disconnect and reconnect fixed wiring equipment
Plumbing / Gas Fitting Equipment
Locate and rectify faults in 250V equipment
Commercial Equipment
Locate and rectify faults in 650V equipment
Industrial Equipment
Attach flexible cord and plug to 250V equipment
Refrigeration and Air Conditioning Equipment
Instrumentation / Process Control Equipment
Communications / Computing Equipment
Laboratory / Scientific Equipment
Gas Fitting License
Do you have a gas fitting license?
Yes
Cert/Ref Number:
Expiry Date
/
/
State
YES, select the relevant classifications below:
G Class
F-126
I Class
E Class
P Class
Page 4 of 10
Any restrictions?
25/03/2014
Registration of Interest
Drivers License Information
Cert/Ref Number
Expiry Date:
/
/
State Issued
C
Car
MC
Multi Combination
LR
Light Rigid
R-N
Moped
MR
Medium Rigid
R-E
Motorcycle (max 250cc)
HR
Heavy Rigid
R
Motorcycle
HC
Heavy Combination
F
Endorsement Commercial
Passenger Vehicle (Bus)
Highest Education
Name of Organisation:
State
High School
Bachelor Degree
Trade Certification
Masters Degree
Certificate II
PHD
Year Completed
Certificate III
Certificate IV
Diploma
Description of Qualification
Dangerous Goods and Explosives
Shotfirers Permit
Do you have a valid WA Shotfirers
Permit?
No
Cert/Ref
Number
Expiry Date
/
/
State
Yes
No
Cert/Ref
Number
Expiry Date
/
/
State
Yes
No
Cert/Ref
Number:
Expiry Date
/
/
State
Yes
No
Cert/Ref
Number
Expiry Date
/
/
State
Yes
No
Cert/Ref
Number
Expiry Date
/
/
State
Yes
Bulk Dangerous Goods Drivers License
Do you have a valid Bulk
Dangerous Goods Drivers
License?
Explosives Drivers License
Do you have a valid Explosives
Drivers License?
Dangerous Goods Security Card
Do you have a valid WA
Dangerous Goods License
Security License
Do you have a security license?
If YES, select the relevant category and provide required information
Security Officer License
License Number
Expiry Date
/
/
State
Crowd Controller License
License Number
Expiry Date
/
/
State
Date of Issue
/
/
State
OHS Construction Blue/White Card
Do you have an OHS Construction
Yes
Industry Card
Maritime Security Identification Card (MSIC)
No
Cert/Ref
Number
A MSIC card is a mandatory requirement if access to the Wharf/Barrow Island is required.
Do you hold a valid Maritime Security Identification Card? (The card must have been received for clearance to employ)
If No; have you applied for a Maritime S e c u r i t y Identification Card?
Yes
No
MSIC Card Number
Expiry Date
/
/
Yes
/
/
No
MSIC Application Number
Application Date
National Police Clearance (NPC)
A NPC is a mandatory requirement for employment with Caledonia (will accept if have current within 6 months of time of employment application)
Do you hold a valid National Police Clearance? (The card must have been received for clearance to employ)
If No; have you applied for a National Police Clearance?
Yes
No
NPC Reference Number
Expiry Date
/
/
Yes
Application Date
/
/
F-126
No
NPC Application Number
Page 5 of 10
25/03/2014
Registration of Interest
Qualification
Metals, Manufacturing and Services
Mechanical Fitter
Cert/Ref Number
Year Completed
State
Metal Machinist
Cert/Ref Number
Year Completed
State
Fitter and Machinist
Cert/Ref Number
Year Completed
State
Metal Fabrication
Cert/Ref Number
Year Completed
State
Sheetmetal Work
Cert/Ref Number
Year Completed
State
Welding
Cert/Ref Number
Year Completed
State
Refrigeration and Air-conditioning Mechanic
Cert/Ref Number
Year Completed
State
General Mechanical Engineering
Cert/Ref Number
Year Completed
State
General Fabrication Engineering
Cert/Ref Number
Year Completed
State
Automotive Electrician
Cert/Ref Number
Year Completed
State
Automotive Technician (Light)
Cert/Ref Number
Year Completed
State
Automotive Technician (Heavy)
Cert/Ref Number
Year Completed
State
Automotive Technician (Marine Light)
Cert/Ref Number
Year Completed
State
Automotive Technician (Motorcycle)
Cert/Ref Number
Year Completed
State
Automotive Technician (Outdoor Power Equip) Cert/Ref Number
Year Completed
State
Automotive
Electrical and Electronics
Electrical
Cert/Ref Number
Year Completed
State
Cable Joiner
Cert/Ref Number
Year Completed
State
Electronic Instrument
Cert/Ref Number
Year Completed
State
Electrical Powerline
Cert/Ref Number
Year Completed
State
Construction
Bricklaying
Cert/Ref Number
Year Completed
State
Bricklaying (Housing)
Cert/Ref Number
Year Completed
State
Carpentry and Joinery
Cert/Ref Number
Year Completed
State
Carpentry (Housing)
Cert/Ref Number
Year Completed
State
Carpentry Fixing (Housing)
Cert/Ref Number
Year Completed
State
Carpentry Formwork (Housing)
Cert/Ref Number
Year Completed
State
Carpentry Framing (Housing)
Cert/Ref Number
Year Completed
State
Joinery (Housing)
Cert/Ref Number
Year Completed
State
Painting and Decorating
Cert/Ref Number
Year Completed
State
Plumbing and Gas Fitting
Cert/Ref Number
Year Completed
State
Drainer
Cert/Ref Number
Year Completed
State
Roof Plumbing
Cert/Ref Number
Year Completed
State
Roof Tiling
Cert/Ref Number
Year Completed
State
Sprinkler Fitting
Cert/Ref Number
Year Completed
State
Steel Framing(Housing)
Cert/Ref Number
Year Completed
State
Wall and Ceiling Fixing (Housing)
Cert/Ref Number
Year Completed
State
Wall and Floor Tiling (Housing)
Cert/Ref Number
Year Completed
State
Wall and Floor Tiling
Cert/Ref Number
Year Completed
State
Floor Finishing
Cert/Ref Number
Year Completed
State
Chef
Cert/Ref Number
Year Completed
State
Cert/Ref Number
Year Completed
State
Food
Other Trades
D Driller
F-126
Page 6 of 10
25/03/2014
Employment History
Beginning with your current or most recent employment, please provide details of the last FIVE years including any periods of unemployment.
IMPORTANT: We will contact any of your previous employers listed below for the purpose of confirming your employment details and determining
your suitability for employment.
May we also contact your CURRENT employer
Company Name
Telephone number/s:
From
/
Reasons for leaving
Company Name
Position held
Name of Supervisor
/
/
Reasons for leaving
Company Name
Position held
Name of Supervisor
Telephone number/s:
From
/
/
Location/Project
Reasons for leaving
Company Name
Position held
Name of Supervisor
Telephone number/s:
Employment dates
From
/
/
Location/Project
Reasons for leaving
Company Name
Position held
Name of Supervisor
Telephone number/s:
Employment dates
From
/
/
Location/Project
Reasons for leaving
Company Name
Position held
Name of Supervisor
Telephone number/s:
Employment dates
From
/
/
Location/Project
Reasons for leaving
Company Name
Position held
Name of Supervisor
Telephone number/s:
Employment dates
From
/
/
Location/Project
Reasons for leaving
Company Name
Position held
Name of Supervisor
Telephone number/s:
Employment dates
From
/
/
Location/Project
Reasons for leaving
Company Name
Position held
Name of Supervisor
Employment dates
Location/Project
To
/
/
To
/
/
To
/
/
To
/
/
To
/
/
To
/
/
To
/
/
To
/
/
To
/
/
Telephone number/s:
From
Location/Project
Employment dates
F-126
/
Location/Project
Employment dates
No
Position held
Name of Supervisor
Employment dates
Yes
Telephone number/s:
From
/
/
Reasons for leaving
Page 7 of 10
25/03/2014
Previous Employment History (Provide further information here if insufficient space above to cover the last five years)
Employment Dates
Company Name
Position Held
Name of Supervisor
Telephone Number
(Month/Year)
Location of Project
Preferred Work Location
Perth
Adelaide
Darwin
Melbourne
Sydney
Brisbane
Western Australia
South Australia
Northern Territory
Victoria
New South Wales
Queensland
Only FIFO work
Within DIDO area
Rosters
(Please tick your preferred Roster)
5days on /2 days off
26 days on/9 days off
2 weeks on /2 weeks
off
Other
3 weeks on /1 week off
8 days on/ 6 days off
Other
Availability
Availability to attend an Interview
Notice Period
F-126
Immediately
1 Hour
As required
1 Day
Page 8 of 10
< 2 Weeks
24 hours notice
>4 weeks
25/03/2014
Health
A previous Workers’ Compensation claim is not a barrier to the consideration of an application for employment. To assist in assessing opportunities for
placement in appropriate employment, please complete this section accurately.
The information provided in this section may be made available to an insurer in connection with any claim for workers compensation. A worker may not be
eligible for compensation for an injury or disability sustained in the workplace where it is proved that the worker made wilful and false representations as not
having previously sustained the injury or disability at the time of seeking or entering employment. Therefore, it is important that
your answers are correct
Have you ever made a claim for Worker's Compensation?
Yes
No
Description of Injury or Disability
Date Occurred
(If YES, please provide details below)
Duration
Employer
A disability or injury is not a barrier to the consideration of an application for employment. To assist in assessing opportunities for placement inappropriate
employment, please complete the following
Do you have a disability, injury, illness or condition that may affect any aspect of your work performance
Yes
No
or that may be aggravated or accelerated by the type of work you are applying for?
If you answered YES to the above, please provide brief details
Are you currently taking any prescription medications?
Yes
No
Yes
No
Yes
No
If you answered YES to the above, please provide brief details:
Do you have any allergies?
If you answered YES to the above, please provide brief details:
Do you wear contact lenses of prescription glasses?
If you answered YES to the above, please provide brief details
Fitness for Duty
It is important that you be medically fit to perform the duties associated with the occupation or positions you are registering or applying for
Do you agree to undergo a full pre-employment medical assessment (including a drug and alcohol screen) at the
Yes
Companys expense?
Part of the Companys Fitness for Work policy includes a random Drug and Alcohol Program to help ensure
Yes
employees are not impaired whilst at work. Do you agree to participate in this Program?
Depending on the requirements of the work and position held , some activities may be carried out at heights. Is
Yes
there any medical condition or other reason to prevent you working at heights?
No
No
No
Do you agree to not be in possession of, under the influence of, or consume intoxicating liquor or drugs?
Yes
No
Other Employment/ Project /Site Requirements
It is very important to observe certain rules and requirements when employed by Caledonia. Are you prepared to
Comply with all Company and Project/Site safety rules and procedures?
Yes
No
Wear and use Project/Site security swipe and identification card (if applicable) to enter and leave sites?
Yes
No
Wear and use the appropriate safety harness or other safety measures when working at heights?
Yes
No
Comply with all security requirements including vehicle, baggage and personal searches?
Yes
No
Wear and use the correct personal protective equipment?
Yes
No
Not use, carry, or be in possession of any weapons or firearms?
Yes
No
Not use, carry or be in the possession of any matches, lighters or other spark emitting devices on site unless
authorised?
Yes
No
Agree to work shift work if required, subject to being medically fit to do so?
Yes
No
Agree to abide by Accommodation /Village/Site Conditionsof Occupancy (where applicable)?
Yes
No
Agree that if I leave Caledonia Scaffolding on my own terms within 3 months of date of commencement, all
costs associated with training and mobilisation will be deducted from my final pay. (permanent employees
only)
Yes
No
F-126
Page 9 of 10
25/03/2014
Other Project requirements
If you are engaged on a specific project, the following declaration will determine your usual place of residence for mobilisation/demobilisation purposes. (only
where applicable)
I, ……………………………………………………………………………………………………………………….. declare that my usual place of residence is:
…………………………………………………………………………………………………………………………. Post Code: ………………………………........
Telephone (
)……………………………………………………
I understand that this declaration determines, for the duration of my employment, any mobilisation /demobilisation or any other entitlements
Signed: ………………………………………………………………………………………..
Declaration
If I am considered suitable for an interview I understand that the information I have provided, and subsequent confirmation of my work history by Caledonia, shall
be provided to any Project/Client or Project/Clients authorised service provider, for the purpose of confirming my suitability for employment.
If I am offered and accept employment, the information will be provided to the Project/Site/Client about my mobilisation, including that I have satisfactorily met
pre-employment checks, such as a Fitness for Work Medical; and information gathered during the recruitment process, such as induction and training records
and other records deemed necessary for the sole purposes of employment.
I understand that if I am offered and accept employment Caledonia may provide the information to authorised service providers, engaged to manage
relating to employment on any Project/Site.
matters
I understand that the information may also be used and disclosed by the Project/Site/Client for the purpose of confirming my suitability for employment
opportunities in connection with other projects that may arise in the future, and for managing matters in connection with my employment on other future
projects.
Should I be engaged with a contractor organisation on the Project/Site and subsequently be engaged with a new or additional contractor organisation, I
authorise the information held about me by the Project/Site to be made available to that new or additional contractor organisation.
I certify that the information set out in this form to the best of my knowledge, true and accurate.
I understand that Caledonia reserves the right to verify all information and any false statements will be sufficient to cause my rejection as an applicant,
dismissal if hired, or termination of my agreement.
my
Caledonia will only collect, use, disclose and manage your personal information in a manner which is consistent with its obligations under Australian privacy laws
and legislation.
Signature
I, ………………………………………………………………………………………………………………….. have read, understood and agree to the terms
above.
(print name)
……………………………………………………………………………………………………………………………………. ………
(Signature)
Date:
Return this form to
Email: recruitment@calwa.com.au
Human Resources
Caledonia
PO Box 4020
Alexander Heights WA
F-126
25/03/2014
Page 10 of 10
……./…………../……………
dd/mm/yyyy