CQ Recruitment Application (General) HR Emp. 01

Employee Application Camperdown Dairy for Employment International

REGISTRATION FORM Note: All information given on this form will remain confidential in accordance with the privacy Amendment (Private Sector) Act 2000 and the National Principles (NPP’s) which are set out in the Act.

Family name...... …… Given Names...... ………………………………..

Address...... Town...... Post Code......

Telephone Home...... Mobile…………………………….

Date of Birth ..……/…..../……. (Not compulsory) Email ………………………………………………………..

Are you legally able to work in Australia Yes No

Are you registered with Centrelink Yes No

Are you registered with a Job Network Provider Yes No

If yes please name provider……………………………………………………………………….

Job Search ID No...... …………….

Licenses currently held (Please Circle): M’cycle, Car, Light Truck, Medium Truck, Heavy Truck, Articulated, Combination, Bus, Taxi, Fork Truck, Skid Steer, Chemical, Security, Excavator, Chainsaw, 1st. Aid, Others, please name …………………………………………………………………………………………………. …………………………………………………………………………………………………………………………...

Seeking work in: (Briefly, please outline the type(s) of work desired, any special work skills or attributes, and any limitations or restrictions you wish consultants to consider when assessing your suitability for positions.

…………………………………………………………………………………………………………………………... …………………………………………………………………………………………………………………………... …………………………………………………………………………………………………………………………... …………………………………………………………………………………………………………………………... …………………………………………………………………………………………………………………………... ……………………………………………………………………………………………………………………………

CQR\Emp\ Application General (Issue 2- 16/08/2010) Page 1 of 4 CQ Recruitment Application (General) HR Emp. 01

Formal / Trade Qualifications if any, or previous experience gained.

______Forklift license: Yes / No

Are you a smoker: Yes / No

Do you have any pre-existing injuries or medical conditions that may prevent you from carrying out the duties of this position? If so, please list details below:

______

Are you in good general health Yes / No

Have/do you suffer/ed from any back strains or injury Yes / No

Have/do you suffer/ed from any joint strains or injury Yes / No

Do you have any allergies or breathing difficulty Yes / No

Have you ever suffered from dizzy spells, fainting or unexplained loss of balance Yes / No

Do you have good eye sight Yes / No

Have you ever suffered a form of hearing loss or deterioration of hearing Yes / No

Please note: The failure to disclose any pre-existing injury or illness will result in sub-section 8 of the Workcover Act applying, which states that the aggravation, recurrence, acceleration, exacerbation or deterioration of undisclosed pre- existing conditions are not entitled to compensation under the Act.

Are you willing to supply a Doctors Certificate if requested? Yes / No

Have you ever had a worker’s compensation claim? Yes / No

Details of claim:

Do you use drugs or prescribed medication of any type?

If Yes, please detail:______

Do you have any criminal convictions of any type?

______

Please Note: This position may require a Police Check (at jobseekers own cost).

Medical History, Health & Fitness:

Pursuant toS.82 (7) & (8) of the Accident Compensation Act which came into effect on 29 June 1998, you are required to disclose to a prospective employer any pre-existing injury or disease that you have suffered of which you are aware and could reasonably expect to foresee could be affected by the nature of proposed employment being applied for.

Do you know of any medical reason why, if appointed, you would be unable to carry out the full requirements of any position applied for? If so please give details.

…..…………………...………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………... Are there any reasonable actions this employer could take to accommodate the issues outlined above, so that you would be able to safely perform the job?

...………………………...………………………………………………………………………………………………

…………………………………………………………………………………………………………………………..

We advise that failure to make a disclosure, making a false or misleading disclosure, would disentitle you to compensation pursuant to the Accident Compensation Act should you suffer any recurrence, aggravation, acceleration exacerbation or deterioration of a pre-existing injury or disease arising from the course of or due to the nature of employment with or through Cartwright McCallum Enterprises P/L. Indeed, Our Company will rely on any failure to disclose in accordance with the provisions of the Accident Compensation Act as grounds for denying compensation in accordance with S.82 (7) & (8)

I consent to any reference checks that may be necessary to support this application

I understand that any false or misleading information given in this application may render my contract of employment, if I am appointed, liable to termination. I declare that to the best of my knowledge the above information, and that submitted in any accompany document(s), is correct.

Signature……………………………………………………………...Date……………………

Position Applied For (If applicable)………………………………………………………………………………

PLEASE NOTE: The CQ Recruitment selection process requires that a resume in Microsoft Word format (not a paper copy) be entered via computer. You must forward (either Email or by disc) a current version to allow our process to be effective.

OFFICE USE ONLY

Reference Checked ______

Qualifications Checked ______

O.H.& S. Orientation ______Date______

Entered on Data Base______Date ______

Consultant ______

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