Behaviour Practitioner Application

APPLICATION FOR EMPLOYMENT

Which location are you applying for? *

NewcastleCentral CoastCoffs Harbour Sydney

What role are you applying for? *

Disability Support WorkerBehaviour Support Practitioner Accounts Administration

Date *

Do you identify as Aboriginal/Torres Strait Islander?

YESNO

First Name *

Surname *

Date of Birth *

Place of birth

State/Country

Do you require a Visa to work in Australia?

YESNO

Please provide a copy of your Visa

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Arrival Date

Type

Email Address *

Mobile *

Home Address *

Home Ph

Suburb *

State *

Postcode *

EMERGENCY CONTACT

Emergency Contact Name *

Relationship

Address

Mobile

Suburb

State

Postcode

What are your income expectations?

DETAILS OF EMPLOYMENT

**Please provide details below ( at least the last three positions held )

Position #1

START DATE OF EMPLOYMENT *

FINISH DATE OF EMPLOYMENT

COMPANY *

POSITION HELD *

REASON FOR LEAVING

Position #2

START DATE OF EMPLOYMENT

FINISH DATE OF EMPLOYMENT

COMPANY

POSITION HELD

REASON FOR LEAVING

Position #3

START DATE OF EMPLOYMENT

FINISH DATE OF EMPLOYMENT

COMPANY

POSITION HELD

REASON FOR LEAVING

Position #4

START DATE OF EMPLOYMENT

FINISH DATE OF EMPLOYMENT

COMPANY

POSITION HELD

REASON FOR LEAVING

Position #5

START DATE OF EMPLOYMENT

FINISH DATE OF EMPLOYMENT

COMPANY

POSITION HELD

REASON FOR LEAVING

Do you need to give notice to current employer? *

YESNO

How Long? *

Do you have any upcoming commitments/pre-booked holidays? *

YESNO

Give Details

Do you have a 2nd Employer / Job? *

YESNO

Give Details

Are you going for other roles elsewhere?

YESNO

Give Details

Are you registered with other recruitment agencies?

YESNO

Give Details

REFEREES / REFERENCE NOMINEES

** WORK references ONLY (not family members or friends)

Must supply MINIMUM OF TWO names and companies who could speak on your behalf

Referee #1

Company *

Person to contact *

Title

Business Phone No. *

How long have you known Referee #1?

Referee #2

Company *

Person to contact *

Title

Business Phone No. *

How long have you known Referee #2?

Referee #3

Company

Person to contact

Title

Business Phone No.

How long have you known Referee #3?

Occupational Licences & Certificates

Please indicate your licences/training (please provide copy/s with your application)

Resume

Please upload current Resume *

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First Aid

First Aid

Please upload First Aid Certificate

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Drivers Licence

C' Class

Please upload Licence *

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Vaccination Certificate

Vaccination Certificate OR Medical Exemption

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Qualifications

Qualifications please upload

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** Please advise your qualifications and provide certificates where possible**

Certificate

Diploma

Trade

Degree

Health and Safety / Medical Questionnarie

Please answer the following questions and provide details where applicable.

Have you ever had any injuries that impacted on your ability to perform work? *

YESNO

Injury #1

Year of injury

Nature of injury

Duration of injury

Any restrictions

Clearance date

Injury #2

Year of injury

Nature of injury

Duration of injury

Any restrictions

Clearance date

Duration of injury

Is a doctor currently treating you for any illness?

YESNO

Details

Are you currently taking any medication?

YESNO

Details

Are you allergic to anything including medications?

YESNO

Details

Have you been away from work because of illness or injury in the last 2 years?

YESNO

Details

Have you ever received treatment for back pain or neck pain?

YESNO

Details

Drugs and Alcohol in the Workplace - Zero Tolerance Policy

We have a zero tolerance policy for the consumption and presence of drugs and alcohol whilst at work.

Drug and Alcohol testing will occur and is on a random basis

Do you have any concerns undergoing Drug and Alcohol testing? *

YESNO

PRIVACY & PERSONAL INFORMATION CONSENT

Please complete the following consent statement

I, *

consent to the collection of necessary personal information, including age, gender, vaccination status, address details, and the disclosure of information to third parties, medical practitioners and psychological service providers.

I agree to undertake all medical tests and examinations as required to ensure my capability to perform the tasks required of the position for which I have applied.

I hereby declare that the information I have provided in this form is true and accurate and I authorise the company to verify any information if required. Any false or misleading information may result in the termination of my position / application.

I have read and understood my rights in respect of access to and collection of my personal information.

Signed

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