/ NORTH COAST PRIMARY HEALTH NETWORK
EMPLOYMENT APPLICATION FORM

POSITION

Position Applied For:
Preferred location (if applicable):
Date: / / /

PERSONAL DETAILS

Surname:
Given Names:
Title:
Address(include town & postcode):
Daytime Phone No:
Mobile Phone No:
Email Address:

Availability:(Please indicate the days and hours you are available to work, e.g.: 9:00am – 5:00pm)

Monday / Tuesday / Wednesday / Thursday / Friday

EDUCATION/TRAINING/QUALIFICATIONS– Please provide details:

Certificates/Degrees Held / Training Period / Name of Institution

REFEREES – Please provide details of (minimum) two current referees:

Name / Position Held & Organisation / Contact Phone Number/s

EMPLOYMENT HISTORY – Please list employment history for the past 5 years, with your most recent position first:

Employer / From (month/year) / To (month/year) / Position / Main Duties

Please select the response that is applicable.

Do you know of any medical reason why you would not be able to perform this role? / Yes/No.
Are you willing for us to contact your previous employers as referees? / Yes/No.
Are you eligible to work in Australia? / Yes/No.
Are you willing to undergo a criminal records/working with children check/credit check? (as appropriate to the position you are applying for) / Yes/No.
Are you a current or recent patient or client of NCPHN services? / Yes/No.

How did you hear about this position? – please tick all that apply:

NCPHN website☐ / Seek☐
Career One☐ / Koori Mail☐
Newspaper advert☐
-If a newspaper, please specify which one:
Other (please specify)☐

Please continue to page 3 to address the key selection criteria

SELECTION CRITERIA– Please complete the table below
  • You must address ALL the selection criteria as set out in the position description (please number each selection criteria response as set out in the position description)
  • This is a compulsory requirement for your application to be considered
  • Attach a separate sheet if you need more space

MANDATORY

/ Personal Attributes

/ Results

/ People Management

/ Relationships

/ Business Enablers
Other mandatory criteria
DESIRABLE
Desirable criteria /
  • Delete row if there are no desirable criteria

I hereby declare that all the information in this application is, to the best of my knowledge, true and correct. I understand that deliberately providing false or misleading information will disqualify me from consideration for the position, and may lead to my dismissal if already employed.

APPLICANT’S SIGNATURE: ______DATE: ______

NCPHN - Employment Application FormPage 1 of 3Rev: 28/04/2016