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					                                                                                                             12 Butcher Street

                                                   EMPLOYEE                                               KWINANA WA 6167
                                                                                                                  PO Box 517
                                           APPLICATION FORM                                              Rockingham WA 6168
                                                                                                         Telephone: 94391555
                                                                                                          Facsimile: 94392010


                                                       APPLICATION
FIRST NAME                                                              LAST NAME
PREFERRED NAME                                                          DATE
POSITION APPLYING FOR

FULL TIME or CASUAL


                                           IMPORTANT- PRIVACY STATEMENT
   Information requested within this application is required for the purpose of considering your suitability for the position for
    which you are applying.
   Should your application be successful this information will be kept on your personal file and an electronic database available
    only to yourself, your Manager(s) and Human Resource Personnel. An exception will be made only where an emergency exists
    and contact details are required.
   Please fill in this form yourself and attach copies of any references, qualifications or other achievements which support your
    application.


                                              PERSONAL INFORMATION
ADDRESS
(HOME) Phone Number

(MOBILE) Phone Number
DRIVERS LICENCE Number                                                        EXPIRY DATE
DRIVERS LICENCE ISSUED            WA, SA, VIC, ACT, NSW, QLD, NT              CATEGORIES
DATE of BIRTH
MARITAL STATUS

NEXT of KIN
NAME
ADDRESS

(HOME) Phone Number
(MOBILE) Phone Number
RELATIONSHIP


                                      ELIGIBILITY TO WORK IN AUSTRALIA
ARE YOU AN AUSTRALIAN RESIDENT                           YES                                      NO

DO YOU HAVE A CURRENT WORK PERMIT                        YES                                      NO




     TCD-IMS-ADM-FOR-007                                           Jul 2010                                    Page 1 of 5
                                                                                     12 Butcher Street

                                        EMPLOYEE                                  KWINANA WA 6167
                                                                                          PO Box 517
                                  APPLICATION FORM                               Rockingham WA 6168
                                                                                 Telephone: 94391555
                                                                                  Facsimile: 94392010


                                    TRAINING & EDUCATION
LAST SCHOOL ATTENDED
HIGHEST YEAR REACHED
CURRENT STUDY / TRAINING


OTHER WORK QUALIFICATIONS


OTHER WORK SKILLS


DO YOU HAVE EXPERIENCE, TRAINING or CERTIFICATION IN ANY OF THE FOLLOWING?
         SUBJECT          SOME EXPERIENCE   ALOT of EXPERIENCE   TICKET/CARD NUMBER    EXPIRY DATE
BLUE / WHITE CARD
PVC PIPELAYING
CCF/ALINTA GAS TICKET
FIRST AID
QUICK CUT
DUMPY / LASER LEVEL
TRAFFIC MANAGEMENT
PLANT OPERATOR
FORKLIFT OPERATOR
DOGGING CERTIFICATE
EXCAVATOR OPERATOR

LOADER OPERATOR
SUPERVISORY SKILLS
WELDING

BRICKLAYING
CABLE LAYING
UNDERGROUND POWER

HEALTH, SAFETY, ENVIRO
OTHER:




    TCD-IMS-ADM-FOR-007                              Jul 2010                         Page 2 of 5
                                                                                                              12 Butcher Street

                                                    EMPLOYEE                                               KWINANA WA 6167
                                                                                                                   PO Box 517
                                            APPLICATION FORM                                              Rockingham WA 6168
                                                                                                          Telephone: 94391555
                                                                                                           Facsimile: 94392010


                                                EMPLOYMENT HISTORY
 EMPLOYER NAME                                                      POSITION TITLE
 EMPLOYED FROM                                                      EMPLOYED TO
 DUTIES & TASKS

 REASON for LEAVING

 EMPLOYER NAME                                                      POSITION TITLE
 EMPLOYED FROM                                                      EMPLOYED TO

 DUTIES & TASKS
 REASON for LEAVING

 EMPLOYER NAME                                                      POSITION TITLE
 EMPLOYED FROM                                                      EMPLOYED TO
 DUTIES & TASKS
 REASON for LEAVING


                                                          REFEREES
 EMPLOYER NAME                                                      POSITION TITLE
 REFEREE NAME                                                       PHONE No.

 EMPLOYER NAME                                                      POSITION TITLE
 REFEREE NAME                                                       PHONE No.

 EMPLOYER NAME                                                      POSITION TITLE
 REFEREE NAME                                                       PHONE No.
I consent to TC Drainage seeking verbal or written information on a confidential basis about me from representatives of my previous
employers and/or referees and authorise the information sought to be released, by those contacted, to TC Drainage for the purpose
of ascertaining my suitability for the position I am applying for.


If you consent to the above SIGN:                                              DATE:



                                                 OTHER INFORMATION
 WHEN CAN YOU START WORK
 WAGE EXPECTATION
 CAREER GOALS

 CAREER HIGHLIGHTS
 HOBBIES & INTERESTS

      TCD-IMS-ADM-FOR-007                                           Jul 2010                                    Page 3 of 5
                                                                                                           12 Butcher Street

                                                  EMPLOYEE                                              KWINANA WA 6167
                                                                                                                PO Box 517
                                          APPLICATION FORM                                             Rockingham WA 6168
                                                                                                       Telephone: 94391555
                                                                                                        Facsimile: 94392010


                                                  MEDICAL HISTORY
Have you ever had a Workers Compensation Claim? If YES, please give details:
Date of Claim:                                                   Nature of Injury:
Employer Name:                                                   Time away from Work:
Was a FINAL medical Certificate issued from the Doctor:
Are there ANY ongoing disability(s) relating to the claim:
                                            FITNESS for WORK                                                        YES       NO
Are you being treated by any Doctor for any illness or taking any medications for a medical condition that TC
Drainage need to be aware of in the case of an emergency?
Are you required to take any medication that may affect your performance at work or affect your attendance?

Are you willing to take a pre-employment medical and which may include a drug & alcohol screening?

Are you willing to take part in any Fit for Work programs which may include random drug & alcohol screenings?
Have you any current medical or surgical conditions that may affect your ability to carry out the position you
have applied for?
Do you have any Medical Condition(s) that need to be monitored regularly, or medical issues your employer
needs to be made aware of to ensure your safety and fitness for work?
Have you had any time off work (more than 3 days at one time) in the last year?
Have you ever had a serious back, neck, shoulder, arm, knee or joints problem?

Is there any reason why you cannot wear safety clothing i.e. Hard hat, vest, boots, gloves, ear plugs?
Have you had a Tetanus injection or Tetanus booster in the last ten years?
Are you affected by “Working at Heights” or “Confined Spaces” at all?
Do you suffer from any of the following ailments or have difficulty with any of the following activities? YES or NO
High Blood Pressure                         Visual Impairments                          Climbing a Ladder

Lung problems / Asthma                      Stomach problems, Ulcers                    Lifting or Bending

Tuberculosis                                Joint problem, Fractures                    Using Hand Tools

Hernia                                      Hepatitis, Jaundice, Liver                  Reading plans & Procedures

Fits, Seizures, Blackouts                   Skin disorders                              Walking on Rough Ground

Headaches, Migraines                        Health effects from dust                    Gripping both hands firmly

Diabetes                                    Food allergies                              Turning your head quickly

Repetitive Strain Injury                    Kneeling, Squatting, Crouching              Repetitive hand movements

Arthritis, Rheumatism                       Standing for > 2 hours                      Repetitive arm movements

Mental, Nervous troubles                    Sitting for > 2 hours                       Repetitive leg movements

Loss of Hearing                             Hearing a conversation                      General Manual Handling

Ear Infections, Dizziness                   Understanding English                       Lifting < or up to 25kgs

     TCD-IMS-ADM-FOR-007                                            Jul 2010                                    Page 4 of 5
                                                                                                                                                   12 Butcher Street

                                                                              EMPLOYEE                                                          KWINANA WA 6167
                                                                                                                                                        PO Box 517
                                                                  APPLICATION FORM                                                             Rockingham WA 6168
                                                                                                                                               Telephone: 94391555
                                                                                                                                                Facsimile: 94392010


                                                                       FITNESS for WORK Continued
 Have you had any exposure to the following in your past jobs?
                       SUBJECT                                      YES / NO                                            If YES please give details.
 Loud noise, explosions, gunfire
 Asbestos
 Chemicals
 Radiation
 Dust
NOTE: TC Drainage may require applicants to have a health assessment, which may include testing for illicit drugs, prior to
employment being confirmed.
Applicants are advised that TC Drainage promote a Smoke Free environment and smoking in any TC Drainage office, vehicle, plant &
equipment or where there is a risk of fire is prohibited.



                                                                                     DECLARATION
 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 a disability, a dispute resolution body may in its discretion refuse to award
 compensation which otherwise would be payable.”




 I ………………………………................................. declare that to the best of my knowledge the answers in this application are correct. I
 understand that if any false or deliberately misleading information is given, or any material fact suppressed, I may not be
 accepted, or if I am employed, my employment may be terminated. I also understand that any offer of employment made is
 conditional on my obtaining a medical clearance through the TC Drainage pre-employment medical and I consent and authorise
 the Company’s doctor to conduct an appropriate medical assessment, which may include testing for illicit drugs and for the
 doctor to forward this information to the Company.


 SIGN..............................................................DATE...............................................................




         TCD-IMS-ADM-FOR-007                                                                           Jul 2010                                       Page 5 of 5

				
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