<p> HAZELWOOD</p><p>APPLICATION FOR EMPLOYMENT FORM Please ensure this form is completed before returning your application for employment. Your application cannot be considered further if this form is incomplete.</p><p>Position applied for: Mine Production Personnel</p><p>1. Personal Details</p><p>Given Names: Surname:</p><p>Postal Address:</p><p>Contact Details: Home Ph: Business Ph:</p><p>Mobile Ph: Email:</p><p>Where did you see this position advertised?</p><p>(please specify)</p><p>The Latrobe Valley Express The Age Other Newspaper / Print Media:</p><p>University Website / Noticeboard Internet Website:</p><p>Privacy</p><p>All personal, sensitive and/or health information collected by GDF Suez Hazelwood, or by service providers engaged by GDF SUEZ Hazelwood, is done so in accordance with the GDF SUEZ Hazelwood Privacy Policy. In the event that your application is unsuccessful, we will retain your application & resume on file for 12 months in order for you to be considered for any additional vacancies. Tick the box below if you do not wish to be considered for any additional vacancies: Destroy my application at the conclusion of the hiring process HAZELWOOD</p><p>2. Education PLEASE LIST ALL SECONDARY, POST-SECONDARY, TERTIARY & TRADE QUALIFICATIONS OBTAINED (MOST RECENT FIRST)</p><p>Qualification Years School/Institution Details (Majors, specialisations, etc)</p><p>3. Membership of Professional Associations RELEVANT TO EMPLOYMENT</p><p>4. Employment History PLEASE LIST YOUR LAST THREE POSITIONS, INLCUDING YOUR CURRENT POSITION (MOST RECENT FIRST)</p><p>Last / Present Position:</p><p>Employer:</p><p>Address:</p><p>Position Held: From: To:</p><p>Reason for Leaving:</p><p>Key Duties & Responsibilities: HAZELWOOD</p><p>4. Employment History (Continued)</p><p>Previous Position:</p><p>Employer:</p><p>Address:</p><p>Position Held: From: To:</p><p>Reason for Leaving:</p><p>Key Duties & Responsibilities:</p><p>Previous Position:</p><p>Employer:</p><p>Address:</p><p>Position Held: From: To:</p><p>Reason for Leaving:</p><p>Key Duties & Responsibilities:</p><p>Periods of Unemployment:</p><p>Dates Reason</p><p>5. References Please complete details of people we may contact</p><p>Name Position Organisation Business Address Phone HAZELWOOD</p><p>6. Additional Questions</p><p>. Do you have the legal right to work in Proof of your legal right to work in Australia may be required on offer of employment. Australia? Yes No</p><p>. Do you have any convictions which are less than 10 years old There is no requirement to answer this question if the conviction/s and/or juvenile convictions which are less than 5 years old? have been quashed or have subsequently been pardoned. If yes, please give details:</p><p>Date Court Offence</p><p>. Fitness for work</p><p>Applicants are required to undergo a medical examination by the Company’s medical practitioners as part of GDF SUEZ Hazelwood’s employment process, to ensure that they are able to safely perform the duties of the position applied for. Please indicate any existing medical conditions or past significant illnesses, any injuries or other physical disabilities, and all Worker’s Compensation or Workcover claims. This information is necessary so that the Company’s medical practitioners can be advised prior to conducting any medical examination.</p><p>Date Nature of Injury Employer (if applicable) Claim settled or ongoing</p><p>. Proof of Identity – Documents required as evidance of Identify To validate your identify GDF SUEZ Hazelwood requires that you provide copies of at least one of the following identification cards containing your signature and photograph:  Driver’s License  License to Perform High Risk Work  Passport</p><p>Declaration & Consent</p><p>I hereby declare that: . The information provided in this form is true and complete, and I authorise GDF SUEZ Hazelwood to verify any information I have submitted herein; . I consent to the collection of personal, sensitive and/or health information reasonably required to assess my suitability for the position for which I have applied, by GDF SUEZ Hazelwood and third party service providers collecting information on behalf of GDF SUEZ Hazelwood; and . I authorise that any personal, sensitive and/or health information collected by third party service providers during the recruitment process, may be provided to GDF SUEZ Hazelwood in order for GDF SUEZ Hazelwood to assess my suitability for the position for which I have applied.</p><p>Name (print): Date:</p><p>Signature:</p><p>Please return this completed Application Form (together with your Resume and Key Selection Criteria) to: Rebecca Rogers Human Resources Officer GDF SUEZ Hazelwood Via email at: [email protected] HAZELWOOD</p>