Application for Employment

1. Position Required

Personal Details

1. Title
2. Mr Mrs Miss Ms
3. Surname
4. Given Names
5. Home Phone
6. Mobile Phone
7. Address
8. Suburb
9. Post Code
10. State
11. Email(valid email required)
12. Date of Birth
13. Are you an Australian Resident
14. Yes No
15. Attach Visa Details
16. Do you have any Tickets/Licenses/Certificates/Qualifications?
18. If yes please list:
19. Do you hold a current drivers license
20. C HR HC MC MR No License
21. Are you registered with a job service agency?
22. Yes No
23. Please attach copies of licenses/qualifications

Emergency Contact

1. Name
2. Relationship
3. Contact Number
4. Contact Number
5. Address

WORKERS COMPENSATION HISTORY

1. Workers Compensation History
2. Yes No
3. If YES please provide brief details
4. Please provide details of any work injury that involved Workers Compensation:
5. Please provide: Date, Injury/condition, No. Days off work, Employer, Final Medical Clearance
6. Do you consent to the verification and investigation of your Worker’s Compensation History by Wombi’s Labour Hire and/or our Insurer?
7. Yes No
8. Do you have any other Health concerns or Medical Conditions that you are aware of that may affect your ability to work, or that Wombi’s Labour Hire should be made aware of, as part of our Duty of Care to its Employee’s and Clients?
9. Yes No

MEDICAL HISTORY

1. What is your current Weight?
2. What is your current Height?
3. Do you Smoke?
4. Yes No
5. How many per day?
6. Do you Drink Alcohol?
7. Yes No
8. How many per day?
9. Do you Exercise?
10. Yes No
11. How many times per week?
12. Are you Pregnant?
13. Yes No
14. Have you been hospitalised for any illness/accident or medical condition?
15. Yes No
16. If YES please give details:
17. Have you had any operations?
18. Yes No
19. If YES please list:
20. Do you have a Disability or Illness at present?
21. Yes No
22. If YES please give details:
23. Have you had any time off work in the past 2 years?
24. Yes No
25. If YES please give details:
26. Have you have any problems with your back or neck?
27. Yes No
28. If YES please give details:
29. Have you ever suffered from blood pressure or heart problems?
30. Yes No
31. If YES please give details:
32. Are you taking any medication at the moment?
33. Yes No
34. Please List:
35. Have you had lung problems/asthma/bronchitis?
36. Yes No
37. If YES please list:
38. Have you ever had fits/seizures/blackouts?
39. Yes No
40. If YES please give details:
41. Have you ever had any joint problems/fractures?
42. Yes No
43. If YES please give details:
44. Have you ever had mental or nervous problems?
45. Yes No
46. If YES please give details:
47. Have you ever received treatment for a stress related condition? (ulcers, insomnia, depression, anxiety, panic attacks)
48. Yes No
49. If YES please give details:
50. Have you ever tested positive in any workplace Drug & Alcohol screening test?
51. Yes No
52. If YES please give details:
53. Have you ever had any repetitive strain/overuse injury?
54. Yes No
55. If YES please give details:
56. Do you have Diabetes?
57. Yes No
58. If YES please give details:
59. Have you ever had Tuberculosis/Pleurisy?
60. Yes No
61. If YES please give details:
62. Have you ever had Arthritis/Rheumatism?
63. Yes No
64. If YES please give details:
65. Have you ever had Hepatitis/Jaundice/Liver problems?
66. Yes No
67. If YES please give details:
68. Do you have any allergies?
69. Yes No
70. If YES please give details:
71. Do you have any skin problems? (dermatitis, eczema, psoriasis)
72. Yes No
73. If YES please give details:
74. Have you ever had cancer or a tumour of any kind?
75. Yes No
76. If YES please give details:
77. Do you have any eye defects? (colour blindness, sight defect)
78. Yes No
79. If YES please give details:
80. Do you have any hearing/ear/sinus related problems?
81. Yes No
82. If YES please give details:
83. Do you suffer from migraines or regular headaches?
84. Yes No
85. If YES please give details:
86. Do you suffer from any health related condition that may be affected as the result of being exposed to medications, detergents or pesticides?
87. Yes No
88. If YES please give details:
89. Do you suffer from Epilepsy?
90. Yes No
91. If YES please give details:
92. Do you have any Difficulty with the following activities or tasks?
93. Working at Heights?
94. Yes No
95. Standing for any period of time?
96. Yes No
97. Working in Confined Spaces?
98. Yes No
99. Being in crowded areas?
100. Yes No
101. Lifting anything under 20kg?
102. Yes No
103. Working with noise?
104. Yes No
105. Running 100 metres?
106. Yes No
107. Bending or stretching?
108. Yes No
109. Sitting for any period of time?
110. Yes No
111. Gripping firmly with both hands?
112. Yes No
113. Repetitive hand or arm movements?
114. Yes No
115. Kneeling?
116. Yes No
117. Turning your head?
118. Yes No
119. Understanding English?
120. Yes No
121. Reading or Writing English?
122. Yes No
123. Concentrating?
124. Yes No
125. If YES to any of the above please give details:

WORK HISTORY

1. Please attach Resume
2. Please list your work history below if you are not attaching a resume
3. Company One
4. Company Name
5. Job Description
6. Start Date
7. Finish Date
8. Name of Supervisor
9. Contact No.
10. Location/Project
11. Employment Type:
12. Casual Permanent
13. Your main duties
14. Reason for leaving
15. Company Two
16. Company Name
17. Job Description
18. Start Date
19. Finish Date
20. Name of Supervisor
21. Contact No.
22. Location/Project
23. Employment Type:
24. Casual Permanent
25. Your main duties
26. Reason for leaving
27. Company Three
28. Company Name
29. Job Description
30. Start Date
31. Finish Date
32. Name of Supervisor
33. Contact No.
34. Location/Project
35. Employment Type:
36. Casual Permanent
37. Your main duties
38. Reason for leaving

EMPLOYEE PAY DETAILS

1. It is imperative that you provide the correct information below
2. NAME OF BANK
3. NAME OF BRANCH
4. BANK NUMBER (BSB)
5. ACCOUNT NUMBER
6. NAME OF BANK ACCOUNT IS HELD IN
7. SUPERANNUATION DETAILS FOR ALLOCATION OF FUNDS ACCUMULATED
8. Name of Superannuation Fund
9. Membership No
10. Telephone No
11. Website of Superannuation Fund
12. Our employees are given the choice of the Superannuation fund they wish to have their contributions paid into. Wombi’s Labour Hire has a default fund of ING Life Ltd (Integra Superannuation) which you may join. Please indicate below whether or not you wish to join ING Life Ltd.
13. Yes No
14. Please note there are some private funds that do not allow outside contributions. If the fund you select is one of these funds you will be automatically joined to our default fund of ING Life Ltd (Integra Superannuation).
15. CIRT
16. YES NO
17. Membership No
18. BERT
19. YES NO
20. Membership No
21. LSL
22. YES NO
23. Membership No
24. Additional Details

 

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