EMPLOYEE APPLICATION FORM
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.
False or misleading information or any deliberate omissions will qualify as sufficient reason for the dismissal of
your application
STEP 1: APPLICANT DETAILS
FAMILY NAME:
FIRST NAME(S):
PREFERRED NAME:
DATE OF BIRTH:
STREET ADDRESS:
CITY:
STATE:
COUNTRY:
POSTCODE:
HOME PHONE:
(
)
MOBILE PHONE:
EMAIL:
Are you of Aboriginal or Torres Strait Islander decent?
Yes
No
(Optional question)
Do you hold a current Australian drivers licence?
Yes
No
If yes, Class?
Please indicate the position you are applying for?
TC Drainage has operations based in the Metropolitan area and the North West of WA. We are
able to offer workers a Fly In Fly Out (FIFO) or Drive In Drive Out (DIDO) roster (subject to
availability). Please specify the area you are applying for by ticking the appropriate box.
Metro
North West
STEP 2: ELIGIBILITY TO WORK IN AUSTRALIA
Are you an Australian Resident?
Yes
No
If no, do you have a current work permit?
If on a working permit, Visa Type:

Yes
No
Current Visa expiry date:
If on a working permit and your application for employment is successful; you will be asked to provide all Visa
documentation during the interview process.
STEP 3: EMERGENCY CONTACT DETAILS (NEXT OF KIN)
FAMILY NAME:
FIRST NAME(S):
RELATIONSHIP TO YOU?
BEST CONTACT No.
STREET ADDRESS:
CITY:
STATE:
COUNTRY:
POSTCODE:
HOME PHONE:
TCD-IMS-ADM-FOR-007
(
)
MOBILE PHONE:
EMPLOYEE APPLICATION FORM
Page 1 of 6
STEP 4: EMPLOYMENT HISTORY
PLEASE NOTE



You must provide at least 5 years employment history with any gaps identified and reasons given
(unemployment, study, travel etc.).
Please start at your most recent position and work your way backwards; ensuring all fields are completed.
In submitting this application, you give consent to TCD contacting your previous employers for the purpose of
confirming your suitability for the position you are applying for.
COMPANY NAME
POSITION TITLE
SUPERVISOR NAME
PHONE
EMPLOYED FROM
Month:
Year:
EMPLOYED TO
Month:
Year:
Month:
Year:
Month:
Year:
Month:
Year:
Month:
Year:
DUTIES & TASKS
REASON FOR LEAVING
COMPANY NAME
POSITION TITLE
SUPERVISOR NAME
PHONE
EMPLOYED FROM
Month:
Year:
EMPLOYED TO
DUTIES & TASKS
REASON FOR LEAVING
COMPANY NAME
POSITION TITLE
SUPERVISOR NAME
PHONE
EMPLOYED FROM
Month:
Year:
EMPLOYED TO
DUTIES & TASKS
REASON FOR LEAVING
COMPANY NAME
POSITION TITLE
SUPERVISOR NAME
PHONE
EMPLOYED FROM
Month:
Year:
EMPLOYED TO
DUTIES & TASKS
REASON FOR LEAVING
COMPANY NAME
POSITION TITLE
SUPERVISOR NAME
PHONE
EMPLOYED FROM
Month:
Year:
EMPLOYED TO
DUTIES & TASKS
REASON FOR LEAVING
*Should you require more fields for data entry; please duplicate this page and submit with your application.
TCD-IMS-ADM-FOR-007
EMPLOYEE APPLICATION FORM
Page 2 of 6
STEP 5: REFEREES
COMPANY NAME
POSITION TITLE
REFEREE NAME
PHONE No.
COMPANY NAME
POSITION TITLE
REFEREE NAME
PHONE No.
COMPANY NAME
POSITION TITLE
REFEREE NAME
PHONE No.
STEP 6: EDUCATION
Please tick the appropriate box to indicate the highest level of education you have achieved.
Year 10 High School
Year 11 High School
Year 12 High School
Certificate Level Studies
Trade Qualification
University Qualification
STEP 7: CIVIL EXPERIENCE
Do you have experience in the civil construction industry?
Yes
No
If yes, how long?
Do you have experience in the mining industry?
Yes
No
If yes, how long?
Do you have any supervisory/leading hand experience?
Yes
No
If yes, how long?
STEP 8: LICENSES, TRAINING AND TICKETS
Do you have a current Construction Induction Card
(White/Blue)?
Yes
No
If yes, Number?
Please complete the following section to indicate any plant licenses, qualifications, certificates or training you have
previously undertaken. Please make sure to include any Fire, First Aid and 4WD qualifications.
QUALIFICATION
TCD-IMS-ADM-FOR-007
ISSUED BY
EMPLOYEE APPLICATION FORM
CERT NUMBER
EXPIRY
Page 3 of 6
STEP 9: MOBILE PLANT & EQUIPMENT EXPERIENCE
Please tick the appropriate box to indicate your experience on each machine. Please use the blank spots for any
plant/equipment not listed.
PLANT/EQUIPMENT TYPE
0-6 Mths
6-12 Mths
1-2 Years
2-3 Years
3-4 Years
5+ Years
Excavators
Loaders
Articulated/Dump Truck
Pad Foot/Smooth Drum Roller
Back Hoe
Bobcat
Water Cart
Dozer
Grader
Road Ranger
Forklift
Dumpy/Laser Level
Welding
STEP 10: WORKERS COMPENSATION
PLEASE NOTE
Section 79 of the Workers Compensation and Injury Management Act 1981 “Where it is proved that the worker has, at
the time of seeking or entering employment in respect of which he claims compensation for an injury, wilfully and
falsely represented himself as not having previously suffered from the injury an arbitrator may in the arbitrator’s
discretion refuse to award compensation which otherwise would be payable.”
Signature:
Please sign and date to indicate you have read and understood the statement above: Date:
Have you ever made claim(s) for Workers Compensation?
Yes
No
Nature of Injury?
Date of Claim?
Employer Name?
Claim Duration?
If yes, please provide details below.
For this claim, was a final Medical Certificate issued from the Doctor?
Yes
No
For this claim, are there any ongoing concerns or disability(s)?
Yes
No
For this claim, was a final Medical Certificate issued from the Doctor?
Yes
No
For this claim, are there any ongoing concerns or disability(s)?
Yes
No
Nature of Injury?
Date of Claim?
Employer Name?
Claim Duration?
TCD-IMS-ADM-FOR-007
EMPLOYEE APPLICATION FORM
Page 4 of 6
STEP 11: FITNESS FOR WORK
Are you being treated by any Doctor for any illness or taking any medications for a medical
condition that TC Drainage need to be aware of in the case of an emergency?
Yes
No
Are you required to take any medication that may affect your performance at work or affect your
attendance?
Yes
No
Are you willing to take a pre-employment medical which may include drug & alcohol screening?
Yes
No
Are you willing to take part in any Fit for Work programs which may include random drug & alcohol
screenings?
Yes
No
Have you any current medical or surgical conditions that may affect your ability to carry out the
position you have applied for?
Yes
No
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?
Yes
No
Have you had any time off work (more than 3 days at one time) in the last year?
Yes
No
Do you suffer from night vision blindness or have difficulty seeing at night?
Yes
No
Have you ever had a serious back, neck, shoulder, arm, knee or joints problem?
Yes
No
Is there any reason why you can’t wear safety clothing i.e. Hard hat, vest, boots, gloves, ear plugs?
Yes
No
Have you had a Tetanus injection or Tetanus booster in the last ten years?
Yes
No
Are you affected by “Working at Heights” or “Confined Spaces” at all?
Yes
No
Do you suffer from any of the following ailments or have any difficulty with any of the following activities?
High Blood Pressure
Yes
No
Visual Impairments
Yes
No
Lung problems / Asthma
Yes
No
Stomach problems, Ulcers
Yes
No
Tuberculosis
Yes
No
Joint problem, Fractures
Yes
No
Hernia
Yes
No
Hepatitis, Jaundice, Liver
Yes
No
Fits, Seizures, Blackouts
Yes
No
Skin disorders
Yes
No
Headaches, Migraines
Yes
No
Health effects from dust
Yes
No
Diabetes
Yes
No
Food allergies
Yes
No
Repetitive Strain Injury
Yes
No
Kneeling, Squatting, Crouching
Yes
No
Arthritis, Rheumatism
Yes
No
Standing for > 2 hours
Yes
No
Mental, Nervous troubles
Yes
No
Sitting for > 2 hours
Yes
No
Loss of Hearing
Yes
No
Lifting < or up to 25kgs
Yes
No
Ear Infections, Dizziness
Yes
No
Understanding English
Yes
No
Reading plans & Procedures
Yes
No
Repetitive movements
Yes
No
Gripping both hands firmly
Yes
No
General Manual Handling
Yes
No
Turning your head quickly
Yes
No
Walking on Rough Ground
Yes
No
Climbing a Ladder
Yes
No
Using Hand Tools
Yes
No
TCD-IMS-ADM-FOR-007
EMPLOYEE APPLICATION FORM
Page 5 of 6
STEP 12: FITNESS FOR WORK CONTINUED
Have you had exposure to the following in the past? If yes, please give details
Loud noise, explosions, gunfire
Yes
No
Asbestos
Yes
No
Chemicals
Yes
No
Radiation
Yes
No
Dust
Yes
No
STEP 13: OTHER INFORMATION
When can you start work
Immediately
Other (Please specify date):
Wage Expectation
Career Goals
Career Highlights
Hobbies and Interests
STEP 14: DECLARATION
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
TC Drainage 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.
Signature:________________________
Print Name:_______________________________
Date:____________
STEP 15: SUBMISSION
IN PERSON
12 Butcher Street
Kwinana Beach WA 6167
BY MAIL
PO Box 517
Rockingham WA 6168
BY FAX
(08) 9439 2010
EMAIL
employment@tcdrainage.com.au
TCD-IMS-ADM-FOR-007
EMPLOYEE APPLICATION FORM
Page 6 of 6