Contact Details Last Name Given Names Date of Birth MaleFemale MrsMissMs Residential address Postal address (if different from residential) Home Phone Number Mobile Number Work Phone Number Email Background Information a) What type of work are you looking for? b) Are you currently employed NoYes How much notice do you need to give? c) Do you have a current driver licence? YesNo d) Do you own a registered vehicle or have a regular means of transport to work? YesNo e) Do you own any of the following standard PPE items in good condition? Steel Cap BootsHard HatGlovesSafety GlassesLong PantsLong Sleeved shirts with reflective striping f ) Do you identify yourself as an Aboriginal or Torres Strait Islander? NoYes What language group do you belong to? g) Are you a permanent resident of Australia? NoYes Do you have a working Visa? NoYes Visa Expiry Date 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) Position Employment Dates To Company Name Company Location Description of Duties Reason for Leaving Referee Name Referee's Position Referee's Phone Number Position Employment Dates To Company Name Company Location Description of Duties Reason for Leaving Referee Name Referee's Position Referee's Phone Number Position Employment Dates To Company Name Company Location Description of Duties Reason for Leaving Referee Name Referee's Position Referee's Phone Number Position Employment Dates To Company Name Company Location Description of Duties Reason for Leaving Referee Name Referee's Position Referee's Phone Number 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 YYYY-MM-DD Basic workplace 1st Aid Senior 1st Aid 1st Aid Other: DTEC Four wheel Drive tkt Inductions Number Date YYYY-MM-DD Induction – BHP Induction – BHP Induction – BHP Rail (lev 2) Induction – BHP Rail (lev 4) Induction – Dampier Salt Induction – Port Authority Induction – Team 45 Induction Other: Mine Health Worker Application for Employment Skills, Experience, Qualifications Mths (M) or Yrs (Y) Exp YYYY-MM-DD Accounts- Payable Accounts – Receivable Accounts – MYOB Accounts – MYOB Plus Accounts Other: Accounts – Quickbooks Accounts – Quickbooks Plus Banking Budgeting Cash Handling Computer Networking Credit Control Customer Service Data Bases Other: Data Processing Document Control – Electronic Document Control – Manual Events Coordinator Faxes , Photocopiers Scanners Keyboard skill WPM: Skills, Experience, Qualifications Mths (M) or Yrs (Y) Exp YYYY-MM-DD Legal Documents Mail Medical Reports Meetings and minute Taking MS office – Access MS office - Excel MS office – Outlook MS office – Power Point MS office - Project MS office – Publisher MS office – Word Payroll Petty Cash Reception SAP/GSAP Stock Control Supervision + 51 pp Supervision – 11 to 50 pp Supervision – Less than 10 pp Switchboard Travel Bookings WordPerfect Office Industrial Skills, Experience, Qualifications Mths (M) or Yrs (Y) Exp YYYY-MM-DD Boilermaker/Welder Boilermaking- Steam EO Boilermaking – Turbine TO Confined Space (tkt) Crane – Derrick – CD Crane – Gantry – CB Crane – Hiab <10t – CV Crane – Non slewing – CN Crane – Tower – CT Crane - <=20t – C2 Crane - <= 60t – C6 Crane - <= 100t – C1 Crane- > 100t – C0 Dangerous Goods Dogman – DG Electrical – A Grade Electrical – C Grade Electrical – Restricted Electrical - Instrumentation Fitting - CNC Fitting – Fixed Plant Fitting – Gas Plant FittiFitting - Locomotive Fitting – Machining Fitting – Materials Handling Fitting – Mobile plant - heavy Fitting – Water Treatment Fitting – Welder Forklift – LF Forklift – Order Picking LO Forklift - IT Skills, Experience, Qualifications Mths (M) or Yrs (Y) Exp YYYY-MM-DD Labouring – Construction Labouring – Concrete Labouring – Electrical Labouring – Formwork Labouring – General Labouring – Landscaping Labouring – Mining Labouring – Rail Labouring – Steel Fixing Labouring – Trades Assistant Motor Mechanic Operator – Backhoe Operator - Dozer Operator – Dump Truck Operator – Excavator - +100t Operator – Excavator – Less 100t Operator – FE & Backhoe Operator – FE Loader Operator – Grader Operator – Grader – Final Trim Operator – Roller Operator – Scraper Operator – Skid Steer Operator – Water Cart Operator Other: Rail – ballast Regulators Rail – Boutet Welding Rail – Coverage (tkt) Rail – Flashbutt Welding Rail – Pettibone Operator Application for Employment Skills, Experience, Qualifications Mths (M) or Yrs (Y) Exp YYYY-MM-DD Rail – Pony Operator Rail – Rerailing Rail – Resleepering Rail – Shunting (tkt) Rail – Signals Rail – Tamper Rail – Thermit Welding Rigging – Basic - RB Rigging Intermediate - RI Rigging – Advanced – RA Scaffold Basic – SB Scaffold intermediate –SI Scaffold Advanced - SA Supply/logistics/Contracts Supervising less than 10 pp Supervising – 11 – 50 pp Supervising - +51 pp Skills, Experience, Qualifications Mths (M) or Yrs (Y) Exp YYYY-MM-DD Traffic Control ( Tkt) Warehouse – Store Person Warehouse – Officer Warehouse – Supervisor Welding – Metal Arc Welding – Aluminium Welding – lead soldering Welding – MIG Welding – Oxy Welding – Pipe Welding – Plasma Arc/Cutting Welding – Spot Welding – Stainless Steel Welding – TIG Welding Certificate: Work Platform 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 Name Relationship to you Address Phone Number Mobile Number Privacy Consent I understand that IMMS may collect from me and other persons (such as previous employers and supervisors) who may or may not be nominated by me, information relating to my suitability for employment with IMMS and in the event of employment with IMMS that information may be used by IMMS to manage the employment relationship and to provide employment services in the course of conducting its business. I agree that IMMS may use and disclose information relating to this employment application: To any organisation to which IMMS currently or may in the future provide employment services, 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.