Personal Details

First name

Last name

Email

Phone

Full address

Birthday

Day

Month

Year

Height (in cms)

Weight (in kgs)

Gender

Male

Female

Rather not say

Citizenship Status

Do you identify as Aboriginal or Torres Strait Islander? (Yes/No)

Yes

No

Do you receive services from an employment services provider? (Yes/No)

Yes

No

Employment Provider Name & Location

Consultant Name & Phone

Job Seeker ID

Tickets / Qualifications

Drivers Licence / Proof of ID (Front)

Drivers Licence / Proof of ID (Back)

White Card (Front & Back, 2 uploads)

Birth Certificate / Passport

Qualifications (up to 5 uploads)

Resume

General Health

(Yes/No for each, with details if Yes)*

Do you have any medical conditions?

Yes

No

If yes, describe here...

Are you currently being treated by any doctor?

Yes

No

If yes, describe here...

Does it require urgent treatment or medication?

Yes

No

N/A

If yes, describe here...

Issues with vision (e.g., glasses)?

Yes

No

If yes, describe here...

Issues with hearing (e.g., hearing aid)?

Yes

No

If yes, describe here...

Known allergies requiring medication?

Yes

No

If yes, describe here...

Are you currently taking any non-prescribed substances?

Yes

No

If yes, describe here...

Physical Health

If yes, describe here...

Neurological & Respiratory:

Do you have any of these contions below? Tick boxes

Head injuries, migraines, seizures, unconsciousness

Mental health condition diagnosed?

Respiratory issues (asthma, bronchitis, silicosis, sleep apnea)

None

If yes, describe here...

Occupational Health

If yes, describe here...

References

Name

Company

Phone

Name

Company

Phone

Declaration

I agree all details are truthful and accurate.

I acknowledge failure to disclose pre-existing injuries may affect compensation rights.

Signature

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