Application for employment Personal Information Name First Last Mobile NumberPhoneDate Of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920GenderMaleFemaleCurrent Home Address Street Address Address Line 2 City State / Province / Region Are you interested in:Part-TimeCasualContractorExpected Salary / Hourly Rate($)Current driving licence? Yes No EDUCATION Name and Address of Schools – Qualifications gainedSkills, Qualifications, Licenses, Awards, Training,Present Or Last Position Previous Position: Present Or Last Position:Previous PositionEmployerEmployerAddress:Address:Phone:Phone:Email:Email:Position Title:Position TitleFrom Date Format: MM slash DD slash YYYY From Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY REFERENCES Please provide at least 2 work-related references in the spaces below. List most recent employers, managers, supervisors only. DO NOT list family and friends. If you have just left college, you may supply details of your Head Teacher/Principal. 1 2 Supervisor’s Name:Supervisor’s Name:Name of Company:Name of Company:Address:Address:Phone NumberPhone NumberYour Position:Your Position:MEDICAL HISTORY Provide details of any workers compensation claims lodged with previous employers Nature of Compensation:Date from: Date Format: MM slash DD slash YYYY Date to: Date Format: MM slash DD slash YYYY Are you currently receiving workers compensation?YesNoIf yes, give details:Do you suffer from ANY disability that may impair the execution of your duties in this job? Yes / No If yes, give details:Do you or have ever suffered from any of the following? Any skin disordersYesNoDate Date Format: MM slash DD slash YYYY Any allergiesYesNoDate Date Format: MM slash DD slash YYYY Heart ComplaintYesNoDate Date Format: MM slash DD slash YYYY High Blood PressureYesNoDate Date Format: MM slash DD slash YYYY Earache, Deafness, Hearing LossYesNoDate Date Format: MM slash DD slash YYYY Asthma, Hay FeverYesNoDate Date Format: MM slash DD slash YYYY Injuries to LimbsYesNoDate Date Format: MM slash DD slash YYYY Black outs of fitsYesNoDate Date Format: MM slash DD slash YYYY Eyesight problemsYesNoDate Date Format: MM slash DD slash YYYY A HerniaYesNoDate Date Format: MM slash DD slash YYYY Are you on prescription medicationsYesNoDate Date Format: MM slash DD slash YYYY Any other medical conditionsYesNoDate Date Format: MM slash DD slash YYYY If yes, give details:CRIMINAL RECORDPlease note any criminal convictions. If none, please state. In certain circumstances employment is depend upon obtaining a satisfactory National Police Check and/or Working with Children Check.LEISURE AND INTERESTSPlease note your leisure interests, sports and hobbies, other pastimes etc.CLEANING EXPERIENCE Please answer the questions below in relation to your experience within the cleaning industry.Have you cleaned End of LeaseYesNoAmount:Have you cleaned New Builders CleansYesNoAmount:Have you cleaned residential propertiesYesNoAmount:Window Cleaning ExperienceYesNoAmount:Carpet Cleaning MachinesYesNoAmount:Experience using a window Cleaning MachineYesNoExperience using a steaming machineYesNoExperience using a Poly VACYesNoDECLARATION (Please read this carefully before signing this application I confirm that the above information is complete and correct and that any untrue or misleading information will give my employer the right to terminate any employment contract offered I agree that the employer reserves the right to require me to undergo a medical examination. I understand that should the employer require further information and wish to contact my doctor with a view to obtaining a medical report, the employer will inform me of their intention and obtain my permission prior to contacting my doctor. In addition, I agree that this information will be retained on my personnel file during employment and for up to six years thereafter. I agree that should I be successful in this application, I will, if required, apply for a National Police Check, and/or Working with Children Check. I understand that should I fail to do so, or should the check not be to the satisfaction of my employer, any offer of employment may be withdrawn, or my employment terminated. Date Date Format: MM slash DD slash YYYY
