General Job Application Form

Date*:

To which division do you wish to apply for employment?
TransportEarthmovingMaintenanceAdministration

Surname*

Given Names*:

Street Address*:

Suburb*:

State*

Postcode*

Telephone No:

Mobile Phone No:

Email*:

Date of Birth*:

Drivers Licence No*:

Class*

Expiry Date*:

Are you an Australian citizen?*YesNo

If not, have you been granted permanent residency or a working visa?*YesNo

Next Of Kin* (Name):

Relationship*:

Address*:

Suburb*:

State*:

Postcode*:

Telephone No:

Mobile Phone No:

Years of experience*

Details of skills/trades*:

WHS Construction Induction (White Card): Certificate No*.

WorkCover licences Type*:

Number*:

Other Qualifications or Industry Inductions*:

Employment History for the past 5 years*:

May Mulgoa Quarries contact past employers for a reference?* YesNo

Health and Safety

Do you have, or have you ever had, back problems, cardiac or circulatory disease, repetitive
strain injury or any other health problems that may affect your ability to perform the duties required?
If yes, please state the nature of the health issue below or put N/A

Have you submitted a Workers Compensation claim for any condition that may be exacerbated
and/or affect your ability to carry out the duties required?

YesNo

If yes, please provide details of claim:

Employer:

Date:

Nature of claim:

Affected area: (eg left wrist, shoulder)

Applicants may be required to undergo a medical examination by a Mulgoa Quarries-appointed Doctor, at MQ’s expense, to ascertain suitability for employment. By submitting this application you agree to undergo a medical examination if requested to do so

Declaration:

I declare that the information provided by me in this application is true and correct.
I understand that Mulgoa Quarries will rely on this information to assess my suitability and may
terminate my employment if the information proves to be false or deliberately misleading.

MULGOA QUARRIES Application for Wage Employment

MULGOA QUARRIES
Application for Wage Employment