APPLICANT DETAILS
(All Applicant Details are treated with strict confidentiality)
PLEASE NOTE:
1. Your application may be rejected if relevant documents are not fully completed. (ie. Prohibited Employment Declaration Form not
signed and returned with this form. Use "N/A" for any section which does not apply.)
2. You may attach photocopies (not originals) of educational qualifications, references and applications should not be forwarded in folders.
3. Complete a separate Applicant Details Form for each position for which you wish to be considered.
4. Applications received after the closing date may be rejected.
5. Supplementary information in the form of covering letter and resume should be provided if not already done so.
6. When completed, forward this form and accompanying documentation to the address stated in the Application Kit.
TITLE OF POSITION:
POSITION LOCATION:
PERSONAL PARTICULARS: (Please print clearly)
Title
Surname:
Other Names:
Residential Address: (Must be completed)
Postal Address
Telephone: (Home)
Post Code:
(Work)
(Mobile)
ALTERNATE PERSON TO BE CONTACTED IF NECESSARY
Surname:
Other Names:
Address:
Town / Suburb:
Telephone: (Home)
(Work)
P/Code:
(Mobile)
ARE YOU AN AUSTRALIAN CITIZEN OR PERMANENT RESIDENT?
YES/NO
IF NO, DO YOU HOLD A VALID WORK PERMIT?
YES/NO/NA
EEO RELATED DETAILS: (Optional – for statistical purposes only.
Please circle appropriate response)
Are you Aboriginal?
YES/NO
Are you Torres Strait Islander?
YES/NO
Are you a member of a Minority Group? YES/NO
What is your 1st language? …… …..
Do you have a physical disability?
YES/NO
Do you require Work Place Adjustment? YES/NO
Do you fluently speak any language in addition to English?
.......……………………...........………………
HEALTH STATUS:
It is necessary for the selection panel to be aware of any disability or pre-existing medical condition which could
affect your capacity to carry out any of the duties of a position.
Anti Discrimination legislation and EEO provisions assure you of no discrimination based on disability or medical
condition. If special arrangements would assist your application for the position or in carrying out the duties of the
position, should you be successful, please detail your requirements below. If insufficient space, please attach a
separate sheet.
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Do you have an active Workers Compensation claim lodged? YES/NO. If yes, please give details of any injury
which may affect your capacity to carry out any of the duties of the position for which you have applied.
In some instances a job fitness medical assessment may be requested. If so, the matter will be discussed with
you.
GENERAL:
How did you become aware of this vacancy?
Professional Journal  Word of mouth 
Local paper  Metropolitan paper
Other (please specify)

ANC Web-site

REFEREES
Please provide names and contact details for 2 persons who are able to provide a reference for you regarding
your capacity and suitability to undertake this position:
REFEREE 1
REFEREE 2
Name
Telephone number/s
Your connection to this
person (eg Manager of the
organisation
where
I
currently work)
APPLICANT’S STATEMENT:
I Understand and agree:a. That all statements in this application are correct to my knowledge and that the making of a false statement
may lead to rejection of this application or dismissal if a false statement is detected after appointment;
b. That I am required to submit to a medical examination if requested by an authorised person;
c. That I am required to produce, before commencing duties, documentary evidence of my identity, educational
attainment and current professional registration;
d. That it will be my responsibility to obtain documentary evidence of all my previous service to gain recognition
for Award purposes;
e. That the terms and conditions of my employment will be in accordance with the appropriate industrial award or
agreement and subject to acceptable performance and availability of funds;
f. To work shift work or reasonable overtime as may be required;
g. That if I am employed as a trainee, my continued employment will be subject to maintaining satisfactory
progress in both theoretical and practical training and continued employment after training is dependent on the
availability of a position;
h. That Anglicare North Coast is a smoke free workplace and smoking is not permitted in buildings or vehicles;
i. I understand my commencement is subject to a satisfactory criminal record check;
j. That I will notify the Executive Director (in writing) immediately or no later than within 14 days, should I be
charged with, or convicted of, a criminal offence.
Signature:
Date:
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