CANDIDATE REGISTRATION FORM

What class of License? E.g MR

Do you have own transport?

Are you an Australian Citizen?

Are you Indigenous/Torres Straight Islander?

Are you with a Job Active provider?

Do you have any health condition or disability that you may need assistance with in the workplace?

If yes, would you like to disclose this to any future employer?

If yes, do you require any assistance from future employer?

Current Salary

Frequency

Salary Expectation

Frequency

Which employment are you seeking?

In Case of Emergency

Emergency Contact Phone number/s

Emergency Contact Address

Emergency Contact Email

Referee 1 Phone Number

Referee 2 Phone Number

(Please list from most current, last 2 employers’)

Last or current Employer

Suburb of Employment

Supervisor Name & Title

Skills required for position

Employer 2 Company Name

Suburb of Employment

Supervisor Name & Title

Skills required for position

Please list computer skills and packages have previously used? (including in-house data-bases)

Qualifications/Education/Certificates

Please list any Education, Qualifications, Licenses and Certificates you have completed

I authorise Asquith Workforce to contact references provided by myself on this form, to provide Asquith Workforce clients with the relevant information to my previous employment. I confirm to the best of my knowledge that the information provided on this form and any other documentation I have provided to Asquith Workforce is correct.

Health Questionnaire

Asquith Workforce has duty of care to provide all employees with a safe and healthy workplace. The purpose of this questionnaire is to identify health problems that may make some types of work unsuitable.

* Do you suffer from Asthma or dry cough?

Yes

* Do you suffer from skin rashes, eczema or dermatitis?

Yes

* Do you suffer from an allergic reaction to certain chemicals?

Yes

If YES, name the chemicals:

* Do you suffer ringing in the ears or deafness?

Yes

* Do you have vision problems that are not corrected by prescription glasses?

Yes

If so, then please kindly explain:

* Have you even been diagnosed with a heart condition?

Yes

* Do you experience sudden attacks of giddiness, fainting or blackouts?

Yes

* Do you have any difficulty with fine motor movements, E.G. Setting your watch, tying shoelaces?

Yes

* Do you suffer from any bone or joint problems such as arthritis, rheumatism or limited range of movement of any joint?

Yes

* Do you suffer from recurring back pain?

Yes

* Do you suffer from Epilepsy?

Yes

* Do you suffer from Diabetes?

Yes

* Do you have any other condition that could impact your work, your safety or that of others?

Yes

If so, please kindly explain:

Are there any other health concerns that Asquith Workforce should be aware of?

Are you on any medication that Asquith Workforce should be aware of?

* Have you had any Worker’s Compensation claims?

Yes

If so, what are they details:

I, the applicant named, do declare that information I have given in this health questionnaire is true and correct.

CANDIDATE REGISTRATION FORM

Personal Details

Salary

Working Conditions

In Case of Emergency

Referee Information

Employment History

(Please list from most current, last 2 employers’)

Computer skills

Qualifications/Education/Certificates

Health Questionnaire

Asquith Workforce has duty of care to provide all employees with a safe and healthy workplace. The purpose of this questionnaire is to identify health problems that may make some types of work unsuitable.

Declaration