Employment Application Form

InstructionsThis application form is designed to be completed electronically and then emailed as an attachment. Complete the form by entering the information in the fields provided. Save the form as a Word document.1. The completed form should be forwarded with a copy of your CV to:

disability@sgscc.edu.au or mailed to SGSCC disAbility Employment Application, PO Box 404, JANNALI NSW 2226.

.

Personal Details

Title:      

Surname:      

Given name:      

Preferred name:      

Address:      

Suburb/Town:       State:       Postcode:      

Telephone: (w)       (h)       (m)      

Email address:      

Languages other than English:       If not a permanent resident number of hours a week visa permits:      

Do you have a current Drivers Licence?: Yes or No

What is your Licence Number?:

What is the date of your National Police Check? Police Check ID number:

Do you have a current Children’s Background Check (WWCC)? WWCC ID Number:

Do you have a current First Aid Certificate? Expiry Date:

Do you have a fully comprehensive insured Car:       OR Do you have third party property car insurance?      Are you on Red or Green P plates?      Your Date of Birth:

……../……../………This is a requirement due to the fact that in the person centred program clients are able to request that individuals are matched in age groups. Hobbies and Interests: Please fill in this question below as you may be matched with a client that has requested an outing or goal that matches your hobbies/interests eg. If you like football, you may be asked to accompany a client to a football match. If you like going to the Gym you maybe asked to take a client to a Gym session This might include such things as, Going to the Theatre, Going to Café’s, Sport etc.

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Please indicate when you are able to commence casual work

Days Available Mon: Tues: Wed: Thurs: Fri: Sat: Sun

Hours Available:

MonFrom/To

TuesFrom/To

WedFrom/To

ThursFrom/To

FriFrom/To

SatFrom/To

SunFrom/To

Which Field of employment are you interested (Please tick relevant fields) and tell us more

Community Support Worker

Disabilities

Tell us more:.

Social Support Tell Us More:.

Daily Living Skills Tell us More

Personal Care Tell us more:

Education & Training

QUALIFICATIONS

Qualification Institution Year Completed

COMPUTER SKILLS

Type Advanced Intermediate Basic

Word

Excel

Other

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YOUR EMPLOYMENT DETAILS

Employer Position Dates Duties Reason for leaving

CONTACT DETAILS OF WORK RELATED REFEREES. (One of your referees should include your current/recent supervisor).

Referee 1

Surname:      

Given name:      

Position title:      

Agency or organisation:      

Relationship to applicant:      

Period known:      

Telephone: (w)       (m)      

Email address:      

Referee 2

Surname:      

Given name:      

Position title:      

Agency or organisation:      

Relationship to applicant:      

Period known:      

Telephone: (w)       (m)      

Email address:      

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HEALTH

Are you currently receiving any medical treatment? YES/NO

Please answer 'Yes' or 'No' to indicate whether or not you have suffered, or are currently suffering from any of the following:

Hearing Loss/Impairment Yes/No

Alcohol or Drug Addiction Yes/No

Problems Ear, Nose or Throat Yes/No

Eyesight deficiency Yes/No

Shoulder/Back/Neck/ Injury/Whiplash Yes/No

Stomach Pain or Ulcers Yes/No

Ankle/Knee/Wrist/Elbow Sprain Yes/No

Insomnia Yes/No

Epilepsy Yes/No

Dizziness/Blackouts Yes/No

Repetitive Strain Injury (RSI) Yes/No

Mental Illness/Nervous Disorder Yes/No

Heart or Blood Pressure problems Yes/No

Skin Disorders/Dermatitis/Eczema Yes/No

Hernia Yes/No

Allergies/Asthma Yes/No

If any, please state whether or not your health condition prevents you from carrying out any particular duty in the work place?

WORKER’S COMPENSATIONHave you been on Worker’s Compensation? YES / NO

Please state the nature and time period of any Worker’s Compensation injury

DECLARATION

I am an Australian Resident and/or hold a Visa permitting me to work.I consent for SGSCC disAbility to verify information provided by me for employment screening purposes and to conduct enquiries as may be necessary.I consent for SGSCC disAbility to contact my referees in order to verify information provided by me for employment and work performanceI hereby declare that I am not receiving any payment/treatment associated with any existing workers compensation claimI consent to SGSCC disAbility contacting me on the phone numbers provided by me on weekdays before 9:00am or after 8:30pm; Saturdays before 9:00am or after 5:00pm; and any time on Sundays; for the purpose of presenting me with information on potential work opportunities and any purpose that nay be ancillary to the provision of such employment.I understand that if, I am offered and accept employment, any false or misleading information given by me, in written form or verbally, may lead to termination of employment. I declare that to the best of my knowledge and information provided in relation to my application is true, complete and correct.

This application can be signed at interview if sent electronically

Signature Date:

Please note: Applications may be required to undertake a medical examination as part of the employment application process, which may include testing for alcohol and other drugs to ensure that duties can be performed safely and adequately. All offers of employment will be subject to a Working with Children and AFP Criminal Records Check. All Information contained in this application will be treated as confidential under The Federal Privacy Act 1988.

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