Application Form | Juliana Village – High & Low Level Aged Care

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Mr Peter Smit - Resident

Application Form

Position Applied for :	Commencement Date :
Date :	FT / PT / CAS
PERSONAL
Surname :	Date :
Given Names :	Country of Birth :
Place of Birth :
Address :
Contact Nos. Work :	Post Code :
Driver’s License No :	Home :
Professional Reg. Nos. :
EDUCATION / TRAINING / QUALIFICATIONS (Attach Resume)
Please list relevant education and training you have undertaken and any certificates received.

Attach Resume :
EMPLOYMENT HISTORY (Last 5 years, please list current job first)
Employer :	Contact Phone :
Date :	Position :
Reason for leaving :
REFEREES

SKILLS & EXPERIENCE (List any you feel are relevant to this position)

CIRCLE THE APPROPRIATE RESPONSE
Do you know of any medical reason why you would not be able to perform this role?	YesNo
Are you willing to undertake a medical examination?	YesNo
Are you willing for us to contact your previous employers as referees?	YesNo
Are you eligible to work in Australia?	YesNo
Are you willing to work weekends?	YesNo
Are you willing to work shifts?	YesNo
Are you the subject of any criminal charge(s) still pending before a court, or have you been the subject of criminal conviction(s) or finding(s) of guilt before a Court which are not “pardoned, quashed or spent convictions” under legislation?	YesNo
If YES please provide details:

WHY DO YOU WISH TO APPLY FOR THIS POSITION?

This facility has: Non-smoking policy fire safety and manual handling sessions are compulsory “Relevant criminal record checks will be conducted on applicants recommended for employment”
I hereby declare that the above information is, to the best of my knowledge, true and correct. I understand that deliberately providing false or misleading information will disqualify me from consideration for the position, and will lead to my dismissal if already employed.
Applicants signature :	Date :

PERSONAL

EDUCATION / TRAINING / QUALIFICATIONS (Attach Resume)

EMPLOYMENT HISTORY (Last 5 years, please list current job first)

REFEREES

SKILLS & EXPERIENCE (List any you feel are relevant to this position)

CIRCLE THE APPROPRIATE RESPONSE

If YES please provide details:

WHY DO YOU WISH TO APPLY FOR THIS POSITION?