Employment

Employment Form

Full Name

Date of Birth

Age

Gender

Male Female

Full Address

Contact Number (Home)

Contact Number (Mobile)

Email Address

Are you an Australian Citizen?

Yes No

Best contact method

Best contact time

Morning (9am- 12pm) Afternoon (12pm- 5pm) Evening (5pm-8pm)

Are you aware of any preexisting injury that may be affected by this work? If yes, please disclose any preexisting injury or disease. (Failure to disclose may result in the worker not entitled to work cover)

Medical History

Are you prepared to have a medical examination to confirm your fitness for work?

Yes No

Hobbies and Interests

Availability

How many hours per week would you like to work?

Are you happy to work shifts? (Minimum shift 3 hours)

Yes No

Comments

Duties/ Responsibilities:
The following is a list of duties/ tasks you may be asked to perform as a companion. Please indicate your ability/ willingness to perform each task

Bathe