Employment Application-form

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Employment Pack

➢ Application for Employment
➢ Confidentiality Policy
➢ Police Clearance Notification
➢ Payroll Information
➢ Uniform Supply
➢ Tax File Number Declaration
➢ Employment – General Information
➢ Hesta new member application ( if applicable)
➢ Fair Work Information Statement
➢ Covid 19

Bedingfeld Park Aged Care Facility | 2 - 4 Bedingfeld Road, Pinjarra | Phone: 08 9531 1622

Position applied for

Last Name:

First Name:

Address:

Postcode:

Telephone:

Date of Birth:

MM slash DD slash YYYY

Age:

Drivers Licence No:

Physical and Health History

Physical and Health History IMPORTANT – Section 79 of the Workers Compensation and Rehabilitation Act 1981 “where it is proved that the worker has, at the time of seeking or entering employment in respect of which he/she claims compensation for a disability, wilfully and falsely represented themselves as not having previously suffered from disability, a dispute resolution body may in its discretion refuse to award compensation which otherwise would be payable.”

Please specify any pre-existing Medical Conditions/Injuries/Claims which may affect work for which you have applied:

Untitled

Do you suffer from any back, neck, shoulder or knee complaints?

Yes

If ‘Yes’ give details:

Are you required to take medication that may:

Affect your work performances?

Yes

Affect your attendance at work?

Yes

How much time have you lost from work in the past 3 years for illness?

Details of Previous Employers

Dates

Company

Position

Duties

Reason for leaving

Untitled

List Three Professional Referees

Name

Company

Address

Position

Telephone

Untitled

Have you been previously employed by this company?

Yes

Workers compensation

Workers’ compensation and assistance Act 1981 gives the Workers compensation Board discretion to refuse to award compensation, which would otherwise be payable, where it is proved that the worker has, all the time seeking or entering employment, wilfully and falsely represented himself/herself as not having previously suffered from the disability for which subsequent claim for compensation is made.

Therefore, full, and accurate disclosure of the following questions is required.

Provide details of any Workers Compensational insurance claims.

Employer

Insurance Company

Approx.Date

Nature of Injury

Have you ever had vocational Rehabilitation Training

Yes

Are you presently receiving a disability pension or Workers Compensation payments.

Yes

Payroll Information

Prefix:

Full Name:

Address:

Suburb:

Post code:

Home Phone No:

Mobile No:

Date of Birth:

Tax File No:

Email Address:

Emergency Contact Person :

Phone:

Relationship:

Superannuation

Superannuation Fund:

USI Number:

Membership No:

Self-Managed Super Fund ESA:

ABN

BSB

A/C

Details of bank account for the credit of your pay:

Bank:

Branch:

BSB:

Account Number:

Account Name:

Employment Status

Position:

F/T, P/T, Casual:

Shift work:

Yes

Start Date:

Police Clearance Notification

Please be advised that you will need to provide a current (not more than 3 years old) Police Clearance Certificate before you commence duty.
Applications can be made through your local Post Office or online services listed below:
www.nationalcrimecheck.com.au
www.afp.gov.au

Covid 19 Western Australia

The Visitors to Residential Aged Care Facilities Directions can be found on the Western Australian Government Website. www.wa.gov.au/government/covid-19-coronavirus.gov.au

Please do not come to WORK if you:

➢ have been informed that you are a close contact of a person diagnosed with COVID-19
➢ have been outside of Australia in the past 14 days
➢ have not received a 2021 influenza vaccine if the vaccine is available to you (a vaccine is not available to a person with a medical contraindication or observing the recommended waiting period after receiving a COVID-19 vaccine)
➢ are a quarantine centre worker and have attended a quarantine centre in the past 14 days (unless you wear a face mask and maintain a distance of 1.5m from others where practicable)

DO Not come to work if you have one or more of any of the following symptoms:

➢ a temperature 37.5 degrees or higher
➢ a recent history of fever
➢ symptoms of acute respiratory infection including a cough, sore throat or shortness of breath
➢ loss of smell or taste.
➢ All workers must report to reception for temperature checks.

FLU VACCINATION

The Western Australian Government has made it compulsory for all staff, visitors and contractors to have an updated, 2021 influenza vaccine before entering a residential aged care home.

Applicants Signature:

Date:

In signing this application for employment, I acknowledge that any misrepresentation of facts is sufficient for dismissal.