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To complete your application please fill in the form below.

Contact Details
Background Information




Qualification Year Finalised Name of School or training provider Location
Secondary (High School)
Tertiary (Uni) or Tafe
Trade Studies
Other Courses

(Please complete most recent employment first)





Skills, Qualifications and Experience

From the list below please identify all skills, qualifications and experience that you have obtained during your work history. Where you indicate you hold a licence, industrial ticket or qualification, a copy will need to be provided prior to commencement of employment.

Licences, Tickets and Certificates State Number Expiry Date
Basic workplace 1st Aid
Senior 1st Aid
1st Aid
Four wheel Drive tkt

Inductions Number Date
Induction – BHP
Induction – BHP
Induction – BHP Rail (lev 2)
Induction – BHP Rail (lev 4)
Induction – Dampier Salt
Induction – Port Authority
Induction – Team 45
Mine Health Worker

Application for Employment
Application for Employment
Do any of the following apply to you? No Yes If Yes, please provide details:
Physical disability that impacts on your ability to perform the work you are looking for No Yes
Loss of hearing or hearing aids No Yes
Loss of long or short vision, or corrective lenses No Yes
Allergies that result in physical symptoms No Yes
Problem working at heights No Yes
Requirement to take prescribed medication No Yes


Do any of the following apply to you? No Yes If Yes, please provide details:
Occasional or on going back or neck pain No Yes
Bone fractures or dislocations No Yes
Occasional or ongoing knee or ankle pain No Yes
Occasional or ongoing shoulder, elbow or wrist pain No Yes
Arthritis or rheumatism No Yes
Severe injuries or operations No Yes
Angina or heart problems No Yes
High blood pressure No Yes
Asthma, tuberculosis or pleurisy No Yes
Asthma, tuberculosis or pleurisy No Yes
Hernia No Yes
Kidney or bladder problems No Yes
Cancer or tumour, including skin cancer No Yes
Depression or anxiety No Yes
Epilepsy, fainting or fitting No Yes
Persistent headaches No Yes
Medical examination in the last 12 months No Yes If yes can you provide a copy?
Workers compensation claim No Yes
c) Are you suffering from any other injury, physical or mental condition that has not been stated above that may impact on your ability to perform the duties you are looking for? No Yes
Emergency Contact Details

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  • To Contracted service providers which IMMS may use to perform services on its behalf (such as banks, IT service providers, etc)
  • Where we are under a legal duty to do so, including circumstances where we are under a lawful duty of care to disclose information.


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