Miss

Given Name

EMPLOYMENT APPLICATION FORMPlease complete ALL questions

PERSONAL INFORMATION

Mr Mrs Ms

Surname

Home Address

Contact Number

Date of birth

Email

ELIGIBILITY FOR EMPLOYMENT (Please tick one of the following)

I am an Australian Citizen

I am not an Australian citizen. I have provided or will provide evidence of my right to work in Australia and declare that I am entitled to do so.

Yes NoHave you ever been convicted of a criminal offence? Applicants should note that employment screening will be conducted

Yes No

Yes No

Do you have a current drivers license? License No Expiry Date

Do you have the use of reliable, registered vehicle?

Please specify any language(s) you speak other than English?

Do you hold any educational qualifications and certificates?Please attach current copies

Certificate III in Home & Community Care/Certificate III in Disability Work/Certificate III in Aged Care DHS - Disability Employment Services Clearance National Police ClearanceCurrent Apply First Aid Certificate (BELS)Manual Handling CertificateOther (please specify)

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Your Previous Employment - Please list last three employers, the positions you held and the periods of employment

Employer 1Position Period of employment

Employer 2Position Period of employment

Period of employment

Overnight Care

Employer 3

Position

What type of Support Work are you seeking with Holistic Care SA?

Personal Care Domestic/Home Care

How many hours are you interested in working each week?

Please indicate the times you will be available to work:Time Saturday Sunday Monday Tuesday Wednesday Thursday Friday

Early mornings

Before midday

Afternoons

Evenings

Late night

Your previous work experience in the home care and personal care field?Please tick client groups with which you have previously worked

Older peoplePeople with dementiaChildren with physical disabilitiesChildren with intellectual disabilitiesAdults with physical disabilitiesAdults with intellectual disabilitiesPersons with psychiatric disabilityPreparing meals

Please specify any experience providing specialized personal care services, such as hoist transfers, catheter care

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Other experience, skills or interest - please provide details that may be relevant to the position

Pre-existing injuries or diseases: PLEASE READ CAREFULLY AND ONLY TICK THE CORRECT RESPONSESHolistic Care SA makes every effort to match the worker with the appropriate clients. It is your responsibility to disclose information about any pre-existing injuries or disease. Eg back problems that could reasonably be affected by the nature of the work. Please tick the relevant boxes below:

Yes No

Yes No

Yes No

I have read the position description and understand the nature of the work

I understand and am willing to act in keeping with the vision and values of Holistic Care SA

I declare that I am not aware of any pre-existing injury or disease that may be affected by the Work

I declare that I have a pre-existng injury or disease. Please specify Yes No

**Note: Under Section 82 (7&8) of the Accident Compensation Act 1985 failure to disclose information regarding pre existing injuries or diseases may result in the worker not being entitled to WorkCover compensation for that particular injury or disease in the event of recurrence, aggravation, acceleration, exacerbation or deterioration of the condition.)

Referees - Please provide the names and contact numbers of three referees. At lease 2 of these must be work references

Name Contact Number

Relationship

Emergency Contact

Name

Name

Contact Number

Contact Number Relationship

Applicant's declaration:

I declare that the information I have provided is true and correct and that if I am employed I will follow all Holistic Care SA Policies and Procedures. I agree to you contacting my referees listed above

Signed Date

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