JH Supported Work Application Form

APPLICATION FOR EMPLOYMENT

Date

PERSONAL DETAILS

First Name

Surname

State/Country

Email Address

Mobile

Home Address

Suburb

State

Postcode

EMERGENCY CONTACT

Emergency Contact Name

Relationship

Address

Mobile

Suburb

State

Postcode

DETAILS OF EMPLOYMENT

Please upload your resume. *

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**Please provide details below ( at least the last three positions held )

Position #1

START DATE OF EMPLOYMENT

FINISH DATE OF EMPLOYMENT

COMPANY

POSITION HELD

REASON FOR LEAVING

Position #2

START DATE OF EMPLOYMENT

FINISH DATE OF EMPLOYMENT

COMPANY

POSITION HELD

REASON FOR LEAVING

Position #3

START DATE OF EMPLOYMENT

FINISH DATE OF EMPLOYMENT

COMPANY

POSITION HELD

REASON FOR LEAVING

Position #4

START DATE OF EMPLOYMENT

FINISH DATE OF EMPLOYMENT

COMPANY

POSITION HELD

REASON FOR LEAVING

Position #5

START DATE OF EMPLOYMENT

FINISH DATE OF EMPLOYMENT

COMPANY

POSITION HELD

REASON FOR LEAVING

REFEREES / REFERENCE NOMINEES

** WORK references ONLY (not family members or friends)

Must supply ONE name and company who can speak on your behalf

Referee

Company

Person to contact

Title

Business Phone No.

How long have you known Referee #1?

Occupational Licences & Certificates

Please indicate your licences/training (please provide copy/s with your application)

First Aid

First Aid - Basic

Please upload First Aid - Basic Certificate

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First Aid - Senior

Please upload First Aid - Senior Certificate

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Perform CPR

Please upload Perform CPR Certificate

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Drivers Licence

C' Class

Please upload C' Class Licence

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Qualifications

** Please advise your qualifications and provide certificates where possible**

Certificate

Diploma

Trade

Degree

Health and Safety / Medical Questionnarie

Please answer the following questions and provide details where applicable.

Are you vaccinated to the required level against COVID 19? *

YESNO

Have you ever had any injuries that impacted on your ability to perform work?

YESNO

Injury #1

Year of injury

Nature of injury

Duration of injury

Any restrictions

Clearance date

Injury #2

Year of injury

Nature of injury

Duration of injury

Any restrictions

Clearance date

Injury #3

Year of injury

Nature of injury

Duration of injury

Any restrictions

Clearance date

Drugs and Alcohol in the Workplace - Zero Tolerance Policy

We have a zero tolerance policy for the consumption and presence of drugs and alcohol whilst at work.

Drug and Alcohol testing will occur and is on a random basis

Do you have any concerns undergoing Drug and Alcohol testing?

YESNO

PRIVACY & PERSONAL INFORMATION CONSENT

Please complete the following consent statement

I,

consent to the collection of necessary personal information, including age, gender, medical history / reports, address details, and the disclosure of information to third parties, medical practitioners and psychological service providers.

I agree to undertake all medical tests and examinations as required to ensure my capability to perform the tasks required of the position for which I have applied.

I hereby declare that the information I have provided in this form is true and accurate and I authorise the company to verify any information if required. Any false or misleading information may result in the termination of my position / application.

I have read and understood my rights in respect of access to and collection of my personal information.

Signed

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