Position Applied
Surname		First names
Address
Phone		Mobile
Date of birth		Age
In case of an emergency, notify
Address
Phone

PHYSICAL / HEALTH HISTORY

IMPORTANT
Section 79 of the Workers Compensation & Injury Management Act 1981
"Where it is proved that the worker has, at the time of seeking or entering employment in respect of which he/she claims compensation for a injury, wilfully and falsely represented themselves as not having previously suffered from the injury an arbitrator may in the arbitrator's discretion refuse to award compensation which otherwise would be payable.

Please specify any pre-existing medical condition/injuries/claims which may effect work you are applying for


Do you suffer from any back, neck, shoulder or knee complaint?
Yes No

If yes, give details


Have you ever claimed workers compensation?
Yes No

If yes, give details

Are you an Australian resident?
Yes No


Do you have your own car to travel to work?
Yes No


Have you ever been convicted of a crime - either in Australia or overseas?
Yes No
If yes, give details



Are you able to obtain police clearance?
Yes No


Are you Aboriginal or Torres Strait Islander?
Yes No

Are you required to take medication which may
Affect your work performance?
Yes No

Affect your attendance at work?
Yes No




How many days have you had off from work in the past three years for illness?

Are you willing to take a medical examination?
Yes No

Please select the condition(s) you have had at any time in your life
Blood Pressure Lung problems / Asthma Hernia Fits / Seizures / Blackouts Persistent headaches / migraine Diabetes (sugar) Any joint problems / Fractures Repetitive strain / Overuse injury	Arthritis / Rheumatism Mental or nervous problems Loss of hearing or ear infections Visual impairments Stomach problems / Ulcers Hepatitis / Jaundice / Liver trouble Skin disorders / Dermatitis

HOW DID YOU HEAR ABOUT US?
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Employment Agency

DETAILS OF LAST TWO EMPLOYERS

Dates of Employment
Company
Position

Duties


Contact


Reason for leaving

Dates of Employment
Company
Position

Duties


Contact


Reason for leaving

STATEMENT
I acknowledge that any misrepresentations of facts is sufficient for dismissal
Yes
No

Date

Applicant's email