Miss
Given Name
EMPLOYMENT APPLICATION FORMPlease complete ALL questions
PERSONAL INFORMATION
Mr Mrs Ms
Surname
Home Address
Contact Number
Date of birth
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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