Veritas House Inc

Veritas House Inc.

Position Application Form

Attention:
Position you are applying for:
Your- First Name:
- Middle Name:
- Surname:
- Postal Address:
- Telephone Contact: / Home:Mobile:
- Email Contact:
Why are you interested in working with Veritas House?
What about this position most interests you?
Do you know someone currently working with Veritas House? / Name:
Relationship to you:
Contact number or email:
Personal Referee
(Not a relative): / Name:
Relationship to you:
Contact Number:
Contact Email:
Employer:
Recent Employer (s) / Position Title:
Main Duties:
Period of Employment:
Reason for Leaving:
Referee Name:
Referee Contact Number:
Referee Email:
Employer:
Position Title:
Main Duties:
Period of Employment:
Reason for Leaving:
Referee Name:
Referee Contact Number:
Referee Email:
Do you identify as an Aboriginal and/or Torres Strait Islander? (Optional) / Yes No
Professional Registration(s): / Profession: State/Territory:
Profession: State/Territory:
Educational Qualification(s): / Qualification:
Institution:
Year of completion:
Qualification:
Institution:
Year of completion:
Qualification:
Institution:
Year of completion:
First Aid Qualification(s) / First Aid:Mental Health:
Yes No Yes No
Workers’ Compensation: / Have you ever lodged a claim for workers’ compensation?
Yes No
Do you have a current workers’ compensation claim in progress?
Yes No
Driver’s Licence: / State/Territory: Class:
Fitness for Duty: / Do you have any physical and/or mental condition(s) that may inhibit performance of your duties or affect your ability to work safely?
Yes No
Criminal / Traffic Matters: / Have you ever been charged with or convicted of a criminal offence, been subject to an apprehended violence order or had your driver’s licence suspended or cancelled?
Yes No
Immigration Status:
Please note you will be required to provide proof of your residency status (Visa and Passport) if you are successful through the / Are you a citizen or permanent resident of Australia?
Yes No
If ‘NO”, are you legally entitled to work in Australia.Proof is required.
Staff Conduct: / Are you prepared to abide by and follow the Policy and Procedures and the Staff Conduct of Veritas House Inc.
Yes No
Privacy Statement: / Personal information collected via this application will only be used for the purposes of employment by Veritas House. The information you submit to us may be disclosed to Veritas House staff involved in the recruitment process, and other third parties who assist us in recruitment (eg: referees).
If you choose not to provide the information requested, we may be unable to process your application or consider you for employment.
Consent: / I consent to Veritas House using and disclosing my personal information in the manner describe above.
Yes No
Declaration:
Signature:
Date: / I hereby apply for employment with Veritas House believing that the information provided is true and complete, and acknowledge that my employment may be terminated should Veritas House subsequently find this information to be false and/or misleading.
/ /
Form: / Position Application- / Release Date: / Aug 2015
Pages: / Page 1 of 4