Employment Application
Position you are applying for:
Position Title:
Reference Number:
Location:
Personal/Contact Details
Title: ☐ Mr
☐
Mrs ☐ Miss ☐ Ms ☐ Dr Name:
Date of Birth:
Gender:
☐
Male
☐
Female
Street Address:
Suburb:
State:
Postcode:
Postal Address (if different from above):
Suburb:
State:
Postcode:
Home Phone:
Mobile:
Email:
Australian Citizenship or Residency Status
Are you an Australian Citizen or Permanent Resident?
☐
Yes
☐
No
If no, do you have a Working Visa?
☐
Yes
☐
No
If yes, please provide a copy of your passport.
Probity Checks
Please attach a current Working with Children Clearance (NSW) and/or Working with Vulnerable
People (ACT) along with your National Police Check that has been issued within the last 12 months.
Please refer back to our positions vacant page for more information on how to obtain these probity
checks.
Working with Children Clearance (NSW) and/or Working with Vulnerable People (ACT)
Have you submitted your application for a
WWCC or WWVP?
☐
Yes
☐
No
Clearance/Application Number:
Expiry Date:
Form-F-02-09: Employment Application
Date Revised: October 2015
Version 10
Date printed: 9/02/2016
Page 1 of 7
Employment Application
National Police Check
Have you submitted your application for a
National Police Check
☐
Yes
☐
No
Certificate Number (if applicable):
Issue Date: (must be within 12 Months)
Previous Applications
Yes
☐
No
Do the people you have named above know that you have
☐ Yes
nominated them as a referee?
If no, as a courtesy you should contact them and ask their permission.
☐
No
Have you applied for work with The Disability Trust before?
☐
If yes, please specify:
Date:
Section:
Position:
Referees
Please provide the names of 2 recent work supervisors
Name:
Position:
Organisation:
Phone Numbers:
Relationship:
Name:
Position:
Organisation:
Phone Numbers:
Relationship:
Form-F-02-09: Employment Application
Date Revised: October 2015
Version 10
Date printed: 9/02/2016
Page 2 of 7
Employment Application
General
1.
Is your resume a true and accurate reflection of your work and educational history?
☐ Yes ☐ No
2.
Is all the information both written in your resume, via emails and verbal during
interviews and other communications given to The Disability Trust to the best of
your knowledge true, correct and fully comprehensive?
☐ Yes ☐ No
3.
Have you ever been dismissed from previous employment for misconduct or poor
work performance?
☐ Yes ☐ No
4.
If offered the position, when would you be able to start? Date:
5.
What is your highest qualification received?
6.
Do you provide full permission for the storage and use of your personal and
professional information for the purposes of employment, in line with privacy laws?
☐ Yes ☐ No
7.
Do you have access to a vehicle that is registered and insured?
(Insurance must be additional to Greenslip)
☐ Yes ☐ No
8.
Do you have a current unrestricted Australian driver’s licence?
(Please note any restrictions i.e. S, Y, P1, P2) ………………..
☐ Yes ☐ No
9.
Do you have a criminal history or convictions against you? This includes a serious sex offence or
child related violent offence, driving convictions or any other criminal offences.
☐ No
☐ Yes - please provide details:
Please provide specific details for example the date of the incident, where the incident occurred. You
should include:
-
Incidents that occurred overseas
Incidents when you were found not guilty
Any failures to appear in court
Matters which have not yet been finalised
Please note that if you do not disclose accurate details, this could affect your employment outcome.
Diversity
10. Is English the primary language spoken at home?
☐ Yes
☐ No – do you speak any other languages?
11. Do you identify yourself as Indigenous?
☐ No
☐ Yes
12. Are you a person with a disability?
☐ No
☐ Yes - what type of disability do you have and specify any assistance you may require:
Form-F-02-09: Employment Application
Date Revised: October 2015
Version 10
Date printed: 9/02/2016
Page 3 of 7
Employment Application
Medical and/or Health Conditions
The Disability Trust has an obligation to ensure all its employees have a safe working environment. To
avoid inadvertently placing you in a situation where your safety is at risk we need to ensure we have
done everything reasonably practicable to satisfy ourselves that you are physically and mentally capable
of performing the tasks associated with the position for which you are being considered. To satisfy our
responsibility under the Work Health & Safety legislation please answer the following questions.
Unanswered questions are not acceptable
13. Are you taking/or have you taken and regular medication or any other drugs that may affect your
ability to do the job?
☐ No ☐ Yes - please provide details:
14. Do you have/or have you suffered from any allergies that may affect your ability to do the job?
☐ No ☐ Yes - please provide details:
15. Have you ever been hospitalised?
☐ No ☐ Yes - please provide details:
Do you have or have you ever had any of the following heath conditions?
If yes please comment next to each category:
16. Angina/Heart Attack
☐ No ☐ Yes - please provide details:
17. Rheumatic Fever
☐ No ☐ Yes - please provide details:
18. Dermatitis/Eczema
☐ No ☐ Yes - please provide details:
19. Back Pain
☐ No ☐ Yes - please provide details:
20. Sciatica/Leg Pain
☐ No ☐ Yes - please provide details:
21. Neck Pain
☐ No ☐ Yes - please provide details:
22. Joint Pain/Arthritis
☐ No ☐ Yes - please provide details:
23. Insulin Dependent Diabetes
☐ No ☐ Yes - please provide details:
24. Eye Disorders
☐ No ☐ Yes - please provide details:
25. Hearing Loss
☐ No ☐ Yes - please provide details:
Form-F-02-09: Employment Application
Date Revised: October 2015
Version 10
Date printed: 9/02/2016
Page 4 of 7
Employment Application
26. Epilepsy
☐ No ☐ Yes - please provide details:
27. Frequent Headaches
☐ No ☐ Yes - please provide details:
28. Chronic Degenerative Condition
☐ No ☐ Yes - please provide details:
29. Neurological Condition
☐ No ☐ Yes - please provide details:
30. Mental Health Diagnosis
☐ No ☐ Yes - please provide details:
31. Pneumonia/Pleurisy
☐ No ☐ Yes - please provide details:
32. Emphysema
☐ No ☐ Yes - please provide details:
33. Bronchitis
☐ No ☐ Yes - please provide details:
34. Asthma
☐ No ☐ Yes - please provide details:
35. Has your health ever been affected by sitting or standing for prolonged periods?
☐ No ☐ Yes - please provide details:
36. Has your health ever been affected by completing manual handling tasks?
☐ No ☐ Yes - please provide details:
37. Have you been ever been affected by frequent use of information technology equipment? Eg
computers.
☐ No ☐ Yes - please provide details:
38. Please specify any other condition not mentioned previously that may be aggravated whilst
undertaking the inherit duties of the position or may impact on your ability to carry out the duties of
the position. Other condition/s:
39. Have you ever had a Worker’s Compensation Claim before?
☐ No ☐ Yes - please provide details such as the injury, when it was sustained and if you are fit for
pre-injury duties.
40. Are there any factors which would prevent you from fulfilling the requirements of the job?
☐ No ☐ Yes - please provide details:
Form-F-02-09: Employment Application
Date Revised: October 2015
Version 10
Date printed: 9/02/2016
Page 5 of 7
Employment Application
Please state your availability to work.
Availability
MON
TUE
WED
THU
FRI
SAT
SUN
6 AM -9 AM
9 AM -3 PM
3 PM -9 PM
OVERNIGHTS
Declaration
I certify that the information on this declaration is true and accurate to the best of my knowledge and I
have not withheld any information regarding my past or present health.
If I have disclosed any health conditions above, I consent to my treating doctor or other treating
practitioner providing information to the pre-employment assessment team for the purpose of
assessing my suitability to undertake the duties for which I have applied. Also I agree to attend a
medical examination with an agreed medical practitioner to review the impact of the above health
information I have declared on my ability to perform my duties without affecting my health and safety.
I understand that by signing this form, I authorise The Disability Trust to release information to the preemployment assessment team.
I also understand that if it is found that I have provided false or misleading information I will not be
employed or my contract of employment may be terminated without notice.
Applicant Name:
Date:
Recruitment Process
Shortlisted applicants will be contacted to attend an interview within two weeks after the closing date.
Please ensure your application reaches The Disability Trust by the closing date.
Form-F-02-09: Employment Application
Date Revised: October 2015
Version 10
Date printed: 9/02/2016
Page 6 of 7
Employment Application
EMPLOYMENT APPLICATION CHECKLIST
Before submitting your application, please read the following checklist carefully to
ensure all required documentation is complete and included in your application.
Warning: Incomplete applications may NOT be accepted.
Please submit as part of your application:
☐ Completed Employment Application – this form
☐ Cover letter
☐ A copy of your CURRENT resume with your two most recent work referees
☐ Working with Children/Working with Vulnerable People Clearance Number and Expiry Date
☐ A copy of your current National Police Check
☐ A statement of claims which clearly outlines how each of the essential and desirable criteria have
been met
☐ A copy of your current Driver’s License
If applicable:
☐ Copies of any nationally recognised qualifications held (e.g. Cert III Disability)
☐ A copy of your nationally recognised First Aid certificate
☐ A copy of your Working Visa
☐ A copy of your current Vehicle Registration
☐ A copy of your current Vehicle Insurance (comprehensive or third party property – not Greenslip)
Privacy Declaration: Your personal information will be kept secure and confidential and will be destroyed if you
are not a successful applicant. .
Form-F-02-09: Employment Application
Date Revised: October 2015
Version 10
Date printed: 9/02/2016
Page 7 of 7