Your Name
*
First Name
Middle Name
Last Name
Date of Birth
*
Please select a day
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Day
Please select a month
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Month
Please select a year
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Year
Your Phone Number
*
-
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency contact
*
First Name
Last Name
Emergency contact number
*
-
Area Code
Phone Number
Tickets and IDs - Please upload a copy of your tickets, White card, Drivers license.
*
Browse Files
Cancel
of
What role have you applied for?
*
Do you have the following?
*
White Card
Driver license and Car
MR/HR
Other tickets
Pre-Med Assessment
Pre-Medical Part 1 - Do you have or have you suffered any other the following?
*
Wrist / elbow pain / injury?
Back or spinal pain / injury?
Whiplash or neck pain / injury?
Ankle / knee pain / injury?
Bone fractures / breaks / dislocations?
Repetitive Strain Injury (RSI)?
No to all above
Pre-Medical Part 1 - If you ticketed any of the boxes above, please provide further details below
HEALTH HISTORY
*
Are you currently receiving any medical treatment for any illness, injury or medical condition?
Are you taking any medicationthat your doctor or pharmacist has advised may impact your ability to work?
Do you have a current Workers’ Compensationclaim?
Have you ever had a Workers’ Compensation claimor work-related injury?
Do you suffer from any impairment or disabilityof any type?
Have you had a tetanus injection in the last 3years?
No to all
HEALTH HISTORY -
If you ticketed any of the boxes above, please provide further details below
Treatment or medical advice -
Please Tick if you have any of the following?
*
Lung / Breathing problems?
Asthma / Hay Fever / Allergies?
Arthritis / Rheumatism?
Anxiety / Depression?
Stomach problems / Ulcers?
Liver problems / Hepatitis?
Diabetes?
Kidney / Bladder problems?
Blood pressure / heart problems?
Persistent headaches / Migraines?
Eye problems (other than glasses/contact lenses)?
Hearing / Ear Problems?
Skin disorders / Dermatitis?
Fits / Seizures / Dizziness / Blackouts /Fainting?
Hernia?
Excessive Bleeding / Bruising?
Cancer / Tumours?
No to all
Treatment or medical advice -
If you ticketed any of the boxes above, please provide further details below
PHYSICAL RESTRICTIONS -
Do you have difficulties with any of the below?
*
Running 100 metres
Turning your headrapidly
Walking on unevenground
Using hand tools
Standing for over 2hours
Hearing a normalconversation
Concentrating on atask
Working in confinedspaces
Working in extremes of temperature
Working at heights
Bending repeatedly
Climbing ladders
Crouching
Lifting 20kgs
Gripping firmly withboth hands
Repetitive movements of hands or arms
Reading ordinarynewsprint
Understanding English
Wearing Personal Protective Equipment (PPE)
Using a shovel
Balancing
Do you smoke?
Do you exercise more than 3 times a week?
Do you have more then 3 standard drinks per day?
Have you ever been treatedfor an injury, illness or side effect as a result of being exposed to chemicalsor toxic substances?
Do you suffer from anymedical or health related condition that may be affected as the result of beingexposed to medications, detergents, cleaning solutions and pesticides? (e.g.respiratory conditions such as asthma, dermatitis or eczema, allergic reactionsetc.)
No to all
PHYSICAL RESTRICTIONS -
If you ticket any of the boxes above please provide further details below?
APPLICANT’S DECLARATION
Declaration - Declaration
*
Fair Work Statement
Induction booklet
Casual Contract of Employment
Visa details - What type of Visa are you on?
Please attach a copy of your current passport
Browse Files
Cancel
of
Superannuation Choice Form - Please select either 1. your choice of super fund. 2. You would like us to set you up with a super fund with the employer nominated fund CBUS.
*
Type option 1
Type option 2
Type a question
*
Answer
What is your Tax File Number?
Are you an Australian Resident for Tax Purposes? Yes or No
Do you want to claim the tax free threshold from this payer? Only claim the tax free threshold from one payer at a time, unless your total income from all sources for the financial year will be less than the tax free threshold. (answer no here if you are a foreign resident or working holiday maker, except if you are a foreign resident in receipt of an Australian Government pension or allowance). * Yes or No
Do you have a Higher Education Loan Program (HELP), Student Start up Loan (SSL) or Trade Support Loan (TSL) debt? Yes or no
I declare that the information I have given is true and correct. Yes or No
have you have changed your name since you last
dealt with the ATO, provide your previous family name? if so what was your previous name?
Candidate Declaration - Please sign to declare that the information you have given is true and correct, that you agree to employment with Erie Workforce on the terms and conditions set out in this employment contract.
Submit
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