POSITION SOUGHT Application for Employment Please complete both the front and back of this form (if you have already submitted your resume or are enclosing you do not need to complete the section on page 4. Position Title: Employment Status: Full time Part time Casual Temporary Permanent How did you find out about this position: Health History Questionnaire AAWA Website Internet Newspaper Word of mouth Internal advertisement Other. Surname: PERSONAL DETAILS Given Name: Preferred Name: Address: Suburb: Postcode: Telephone (home): Telephone (Mobile): Email address: ELIGIBILITY TO WORK IN AUSTRALIA Are you an Australian Citizen? The following information is being sought to assess your ability to perform the essential duties required of If NO, have you been granted Permanent Residency? If NO, have you been granted a temporary Visa / Working Permit? If YES, please provide Visa details: These details are used to verify the Work eligibility under the visa Type: Visa Number: Passport Number: Valid From: Valid To Documents/Docs/Workplace/Staff/Forms/Application for Employment Page 1 of 5
HEALTH ASSESSMENT Alzheimer s Australia WA in an Equal Employment Opportunity employer, and therefore a medical condition, disability or previous Workers Compensation claim is not a barrier to the potential offer of employment. To assist us in assessing opportunities, please provide details of any previous or current medical condition or restriction, physical or otherwise, which may affect your ability to perform the inherent and essential requirements of the role. Offers of employment are conditional upon you being assessed as being fit to safely undertake the duties of the proposed position without placing yourself or others at a risk of injury. This must include any medical condition or restriction arising from a previous workers compensation claim. Failure to provide such information may jeopardise your rights to workers compensation if a pre-existing disability is aggravated at work (section 79 of the Workers Compensation and Rehabilitation Act 1981). Please select from the following list any illnesses, injuries or disabilities which you have, or are currently suffering: Visual problems Whiplash Difficulty hearing or with balance Hernia or abdominal ulcers Back/neck trouble or pain Blood or body fluid borne disease Injury of any kind Heart trouble or experiences chest pain Bone fractures or dislocations Seizures/fits, fainting or dizzy spells Knee trouble/pain Psychological or psychiatric problems Ankle trouble/pain i.e. anxiety, depression, stress, panic attacks etc. Foot / toe trouble / pain RSI, Overuse Syndrome or Carpal Skin rashes/problems, eczema, dermatitis Tunnel Syndrome Shortness of breath, asthmas, wheeze or suffer from breathing difficulties Shoulder / elbow or wrist trouble/pain Tuberculosis Hand/finger trouble /pain Immunosupressed including receiving chemotherapy or long term steroid use Allergies or sinusitis Drug or alcohol addiction Health effects from contact with chemicals Exposure to noise in previous employment Tendency to bruise or bleed excessively Diabetes Chronic joint injury including stiffness or pain Rheumatics or arthritis of any kind Persistent headaches Muscle, tendon or ligament problem Sporting, vehicle, work related illness or injury Discharged or resigned from a job due to medical reasons Documents/Docs/Workplace/Staff/Forms/Application for Employment Page 2 of 5
HEALTH ASSESSMENT - Continued If you selected yes for any of the above please provide details including treatment obtained and current state of injury or illness: Are there any duties of the position you have applied for which you are, or may be, unable to do due to health problems or physical disability? If yes, please give details: Have you ever claimed workers compensation? If yes, please give date and details: If yes, is the workers compensation claim still open? Are you still receiving treatment?: Would you be willing to attend a medical examination if considered necessary, If no, please give reasons: Documents/Docs/Workplace/Staff/Forms/Application for Employment Page 3 of 5
Professional / Educational Qualifications Institution Year/s Attended Qualifications Obtained Work Experience Employer From To Position Held Referees Please list the names of two referees that can be contacted to obtain information on your work record and competences Name of referee Telephone / Email Contact Relationship to you General Information Have you previously worked for Alzheimer s Australia WA? Yes If yes state positions held and dates employed.. Do you hold a valid WA Driver s License? Yes Documents/Docs/Workplace/Staff/Forms/Application for Employment Page 4 of 5
If applying for a position as a Support Worker, please complete the below section: To provide us with an indication of your availability and flexibility, please complete the table below: Available to work: EXAMPLE 8am 12pm, 3pm 5pm Available Hours Monday Tuesday Wednesday Thursday Friday Saturday Preferred number of hours per week: Do you have a vehicle to use for work purposes in a condition that would be suitable for transporting people with dementia? Yes Is your vehicle insured? Yes Do you have a current basic or senior first aid certificate? Yes APPLICANT DECLARATION I declare the above information to be true in all respects. I acknowledge that any statement which I have made is found to be false or deliberately misleading will make me, if employed, liable for dismissal. Name: Signed: Date: Please submit your application to: Human Resources Alzheimer s Australia WA PO Box 1509 Subiaco WA 6904 Or Email: Human.Resources@alzheimers.org.au Documents/Docs/Workplace/Staff/Forms/Application for Employment Page 5 of 5