Application for Employment Employment Application Personal Details Title Mr Miss Mrs Ms Name * First Last Name * Last Postal Address * Paragraph Telephone Business Home Home Mobile Mobile Work Related Details Position applied for: * Are you an Australian resident? * Yes No If yes, please attach a copy of Visa to application Drop a file here or click to upload Choose File Maximum upload size: 20.97MB Are you an Aboriginal or Torres Strait Islander? * Yes No Do you speak a language other than English? * Yes No If yes, what language do you speak? Please indicated the type(s) or employment you are seeking: Full time Part time Casual Please indicate your shift availability for: Morning Afternoon Night Weekend In the event that the position you are seeking is not available, are there any other positions for which you wish to be considered? (please describe) Registered Nuses/Enrolled Nurses/Allied Health Professionals/Medical Staff Certificate of General Registration No: Receipt No: Date Professional References Please nominate at least two referees from previous employment/s Name Title Company Name Phone Number Add Remove Qualifications Course Year Commenced Year Completed Name of Institution Add Remove Professional Memberships Employment History Employer Name From Date To Date Position Held Add Remove This section is applicable to Support Workers/Care Assistants only Do you have previous experience in: Food Handling Yes No Patient Care Yes No Cleaning Yes No Pre Employment Immunisation Screening Please complete the following questionnaire if you will have resident contact during your employment, including entering resident's rooms or working in resident contact areas: (The purpose of this questionnaire is to validate immunisation status and screening requirements prior to employment and to ensure that the work place is as far as practicable, safe for employees.) Section 1. Please answer by ticking the application box: 1.1 Chicken Pox Have you had chicken pox? Yes No Have you been immunised? Yes No Have your childrend had chicken pox? Yes No 1.2 Hepatitis B Have you been immunised? Yes No 1.3 Eczema Do you suffer from eczema? Yes No Section 2. Laboratory Screening Requirements 2.1 Multiple Resistant Staphylococcus aureus (MRSA) screening Have you worked in or been a patient in a hospital outside Western Australia in the past twelve (12) months? Yes No If YES, please provide the following details: Name of Hospital: Address: Please note: Any statement found to be false or deliberately mileading may invalidate a worker's compensation claim. Additional Information We invite you to use the space below to provide us with any additional information about yourself which you believe would support your application. Health Please provide details of any previous or current medical conditions or restrictions, physical or otherwise, which may affect your ability to perform the essential requirements of the job. This must include any medical condition or restriction arising from a worker's compensation claim. Failure to provide such information may jeopardise your rights to workers compensation if a pre-existing disablity is aggravated at work (Section 79 of the Workers Compensation and Rehabilitation Act 1981). Certification I certify that the information in this application form is to the best of my knowledge and belief, true and accurate in every detail. I understand that ValleyView Residence reserves the right to verify all information on this application and that any false statements will be considered sufficient cause for rejection of my application or my dismissal if employed. * I acknowlege reCAPTCHA Submit If you are human, leave this field blank.