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PROVIDING FALSE OR MISLEADING INFORMATION ON THIS FORM IS A BREACH OF CONTRACT AND MAY LEAD TO INSTANT DISMISSAL

Personal Particulars

First Name:* Surname:* Preferred Name:
Address: Post Code:
Home Phone:  or Mobile Phone:* Email:
Date of Birth:* Marital Status: Spouse/Partner Name:
Next of Kin:* Telephone:*
 
Have you previously spoken to one of our recruiters? If so, please choose their name: *
Have you worked for Workforce Solutions before? *
How did you hear about Workforce Solutions?

Qualifications

Trade or type of work sought: *
If you have any, what current work licences do you hold?
If you hold any welding codes, what are they?
If you hold a mineworkers health surveillance certificate/card, what number is it?
If you have ever been inducted, when was that?
Drivers licence number:
What class(es) of vehicle are you licenced to drive?
If you have any other qualifications or certificates, what are they?
Have you worked on a mine site?
Have you worked underground?
Do you have your own tools and safety gear? *

Job availability, suitability and preferences
Have you made any workers
compensation claims in the last 5 years?		 *
If you have made any workers compensation claims
in the last 5 years, please provide details and dates:
Do you have your own transport?
Are you a union member?
Which union do you belong to?
Please provide details if you have had
any criminal convictions in the last 5 years? 		*
Are you available for work now? *
Are you currently employed? *
What company are you working for now?
Position:
Period emloyed:
Brief job description:
What level of skills do you have? *
Any preferred location?
What kind of work are you interested in? Temporary Permanent

Work History
Please provide us with details of your last jobs

Job 1
Company Name:
Location:
Position:
Date started:
Date finished:
Brief job description:
Supervisor's Name:
Telephone number:

Job 2
Company Name:
Location:
Position:
Date started:
Date finished:
Brief job description:
Supervisor's Name:
Telephone number:

Job 3
Company Name:
Location:
Position:
Date started:
Date finished:
Brief job description:
Supervisor's Name:
Telephone number:

Health Check
Do you wear spectacles or contact lenses?
Do you have ear problems/deafness? Please provide details: 
Do you have any mouth disorders/dental problems? Please provide details: 
Do you have fainting fit/epilepsy/severe headaches? Please provide details: 
Do you suffer from hay fever/sinusitis?
Do you have any lung problems?
(Asthma, T.B., Bronchitis, breathlessness)		 Please provide details: 
Do you suffer from indigestion,
ulcers, repeated diarrhoea etc.?		 Please provide details: 
Do you suffer from a heart condition -
raised blood pressure, chest pains?		 Please provide details: 
Do you have kidney/bladder problems? Please provide details: 
Do you have troublesome feet/bunions? Please provide details: 
Do you have varicose veins?
Do you suffer from a hernia? Please provide details: 
Do you have hepatitis/diabetes? Please provide details: 
Do you have allergic reactions?
eg. bees, spiders		 Please provide details: 
Do you have dermatits or another skin condition? Please provide details: 
Do you have nervous disorders or
have you had psychiatric treatment?		 Please provide details: 
Have you had any operations or fractures? Please provide details: 
Do you have a knee or joint injury? Please provide details: 
Do you have back pain/back injury? Please provide details: 
Do you have any other conditions
which may affect employment?		 Please provide details: 
Are you a smoker?
Do you drink alcohol?
Do you take regular medication? Please provide details: 
Do you exercise? If so, how often?
What was the date of your last tetanus immunisation?
Do you have a conscientious or other
objection to medical treatment?		 Please provide details: 
Please advise us of your private doctor's name,
address and phone number:
Are there any other health issues
you would like to discuss?

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