Application for Employment & Consent

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KEY DATES Applications Commence 13 December 2011 1 st Round Roster Offer 6 February 2012 2 nd Round Roster Offers 13 Feb - 1 March 2012 RSA & Hygiene Training 20 – 29 February 2012 Uniform Collection & Safety Site Induction 25 February 2012 Clipsal 500 Event 1-4 MARCH 2012 application information & FAQ CONTACT DETAILS Mission Australia Ph: 1300 244 495 Fax: 8409 1099 [email protected] www.employmentsolutions.com.au Clipsal Track Staffing Office-Spotless Ph: Track 8224 0195 30 Jan – 7 March 2012 only Spotless Head Office Ph: 8354 8222 Fax: 8354 8270 www.spotless.com.au 2012 Clipsal 500 Adelaide The Race that Rocks! staff@events in co-operation with Mission Australia Employment Solutions, are excited to again be providing recruitment services to Spotless for corporate and retail catering positions at the 2012 Clipsal 500 Adelaide. We hope you are able to come along and join in the fun, and be part of what makes this state truly GREAT! Clipsal 500 is arguably the worlds best motorsport event - more than 270,000 fans over four days can’t be wrong. Join them at the 2012 Clipsal 500 Adelaide… Want to learn more – visit Clipsal 500 official website www.clipsal500.com.au $ $ Pay Rates Counter Assistants, Kitchen Attendants, General Hands, Waiting Staff, Bar Staff: Level 2 – 18+ yrs $24.86* Level 3 – Supervisor $25.71 Level 4 – Chef $27.09 *Level 2, 15 - 17yrs Junior Rates apply to positions that do not require the service of alcohol. Training Responsible Service of Alcohol and Follow Workplace Hygiene Procedures training will be made available free of charge to any new applicants who do not possess a certificate in these areas. Training will be allocated and confirmed with successful applications only, based on rostered shift type. If you already have been trained in these areas, please provide copy of certificate with your application. Apply in 2 Easy Steps Step 1 Pick up a registration pack from: Mission Australia 54 Currie St, Adelaide; Lvl 1, Windsor Building, 50 Elizabeth Way, Elizabeth City Centre; or Shop 3, 10-14 Regency Rd, Kilkenny Spotless Reception 290 South Rd, Hilton Download @ www.employmentsolutions.com.au Recruitment Sessions - as listed below Step 2 Attend a Recruitment Session: YOU MUST REGISTER & ATTEND A SESSION http://bit.ly/clipsal2012 If possible, please bring completed registration pack places are limited to 100 per session book early to ensure you secure a place at your preferred date and time Friday 13, Saturday 14 & Monday 16 January 2012 Adelaide Entertainment Centre cnr Port Rd & Adam St, Hindmarsh 11am 1.00pm 2.30pm 4.00pm on-site car parking available IF YOU DO NOT HAVE ACCES TO THE INTERNET PLEASE CALL 1300 244 495 Please bring completed applications forms including a current resume of no more than 3 pages, tax file number, bank and superannuation details copy of hospitality training certificates If you are not able to attend any of these session times please notify us 1300 244 495 [email protected] A few smaller registration sessions may be available depending on applications. WORK IS AVAILABLE FOR: Chefs, Cooks, Kitchen Hands, Retail Bars, Drink Stands, Corporate Box Waiting Staff, Stores & General Hands including Supervisory & Management Positions These forms are essential to your employment opportunities and potential payment for work at the Clipsal 500 Adelaide, please ensure you take care to answer all questions and sign and date where required. THESE FORMS ARE A REGISTRATION OF INTEREST ONLY

Transcript of Application for Employment & Consent

Page 1: Application for Employment & Consent

KEY DATES Applications Commence

13 December 2011

1st Round Roster Offer 6 February 2012

2nd Round Roster Offers 13 Feb - 1 March 2012

RSA & Hygiene Training 20 – 29 February 2012

Uniform Collection & Safety Site Induction

25 February 2012

Clipsal 500 Event 1-4 MARCH 2012

application information & FAQ

CONTACT DETAILS

Mission Australia Ph: 1300 244 495 Fax: 8409 1099 [email protected] www.employmentsolutions.com.au

Clipsal Track Staffing Office-Spotless Ph: Track 8224 0195 30 Jan – 7 March 2012 only

Spotless Head Office Ph: 8354 8222 Fax: 8354 8270 www.spotless.com.au

2012 Clipsal 500 Adelaide

The Race that Rocks!

staff@events in co-operation with Mission Australia Employment Solutions, are excited to again be providing recruitment services to Spotless for corporate and retail catering positions at the 2012 Clipsal 500 Adelaide.

We hope you are able to come along and join in the fun, and be part of what makes this state truly GREAT! Clipsal 500 is arguably the worlds best motorsport event - more than 270,000 fans over four days can’t be wrong. Join them at the 2012 Clipsal 500 Adelaide…

Want to learn more – visit Clipsal 500 official website www.clipsal500.com.au

$ $ Pay Rates Counter Assistants, Kitchen Attendants, General Hands, Waiting Staff, Bar Staff: Level 2 – 18+ yrs $24.86* Level 3 – Supervisor $25.71 Level 4 – Chef $27.09 *Level 2, 15 - 17yrs Junior Rates apply to positions that do

not require the service of alcohol.

Training

Responsible Service of Alcohol and Follow Workplace Hygiene Procedures training will be made available free of charge to any new applicants who do not possess a certificate in these areas. Training will be allocated and confirmed with successful applications only, based on rostered shift type. If you already have been trained in these areas, please provide copy of certificate with your application.

Apply in 2 Easy Steps

Step 1 Pick up a registration pack from:

Mission Australia 54 Currie St, Adelaide; Lvl 1, Windsor Building, 50 Elizabeth Way,

Elizabeth City Centre; or Shop 3, 10-14 Regency Rd, Kilkenny

Spotless Reception 290 South Rd, Hilton Download @ www.employmentsolutions.com.au

Recruitment Sessions - as listed below

Step 2 Attend a Recruitment Session:

YOU MUST REGISTER & ATTEND A SESSION http://bit.ly/clipsal2012

If possible, please bring completed registration pack places are limited to 100 per session book early to ensure

you secure a place at your preferred date and time

Friday 13, Saturday 14 & Monday 16 January 2012

Adelaide Entertainment Centre cnr Port Rd & Adam St, Hindmarsh

11am 1.00pm 2.30pm 4.00pm on-site car parking available

IF YOU DO NOT HAVE ACCES TO THE INTERNET PLEASE CALL 1300 244 495

Please bring completed applications forms including a current resume of no more than 3 pages,

tax file number, bank and superannuation details copy of hospitality training certificates

If you are not able to attend any of these

session times please notify us 1300 244 495

[email protected] A few smaller registration sessions may be available

depending on applications.

WORK IS AVAILABLE FOR: Chefs, Cooks, Kitchen Hands, Retail Bars, Drink Stands, Corporate Box Waiting Staff, Stores & General Hands including Supervisory & Management Positions

These forms are essential to your employment opportunities and potential payment for work at the Clipsal 500 Adelaide, please ensure you take care to answer all questions and sign and date where required.

THESE FORMS ARE A REGISTRATION OF INTEREST ONLY

Page 2: Application for Employment & Consent

Frequently Asked Questions

I WORKED FOR SPOTLESS AT CLIPSAL FOR THE 2011 EVENT – DO I NEED TO ATTEND ANOTHER RECRUITMENT SESSION?

NO – you are only required to complete an “Application for Existing Employees”. A form will be sent by Mission Australia to your home in December 2011 or you can download a copy of the form at www.employmentsolutions.com.au

I HAVE NEVER WORKED FOR SPOTLESS AT THE CLIPSAL 500 ADELAIDE BEFORE – DO I NEED TO ATTEND A RECRUITMENT SESSION?

YES – all new applicants to Spotless for the Clipsal 500 Adelaide must attend a recruitment session to register.

DO I HAVE TO REGISTER FOR A RECRUITMENT SESSION?

YES – you are required to register for a recruitment session, http://bit.ly/clipsal2012 we suggest you book early to ensure you secure a place at your preferred date and time.

If you do not have access to the internet please call 1300 244 495.

I AM UNDER THE AGE OF 18 – CAN I STILL APPLY?

Due to the service of alcohol the number of positions available to those applicants under the age of 18 years are limited to: kitchen hands, general hands and some retail counter assistant positions. These positions are very limited and placement cannot be guaranteed.

WHAT IF I DON’T GET INTO A RECRUITMENT SESSION?

You will be given the option to attend another scheduled recruitment session, or if this is not suitable at the time we will accept your registration paperwork and there may be a small number of recruitment session scheduled at a later date depending on number and suitability of applications.

WHAT IS A JOB SEEKER ID? AND DO I NEED TO HAVE ONE TO APPLY FOR WORK?

No, you do not need to have a Job Seeker ID to apply for work. Mission Australia Employment Solutions is a Job Services Australia Provider. If you are a registered Job Seeker or in receipt of a Centerlink payment it is likely you may have a Job Seeker ID. For further information on Job Seeker ID’s or Job Service Australia Providers please contact Centerlink on 13 2850.

IF I APPLY FOR WORK AM I GUARANTEED A POSITION AT THE CLIPSAL 500 ADELAIDE?

NO – due to the large number of applications received for this event the number of positions are sometimes limited, offers of placements will be offered to those with the most suitable experience.

HOW WILL I KNOW IF I HAVE BEEN SUCCESSFUL FOR A POSITION AT THE CLIPSAL 500 ADELAIDE?

An offer of placement roster will be sent to you via email or post. Roster offers will commence on 6 February and subsequent offers of placement will continue from 13 February 2012.

WHAT IF I AM NOT SUCCESSFUL FOR AN OFFER OF PLACEMENT?

If you are not successful for an offer of placement at the Clipsal 500 Adelaide you will be notified by email or post as of 6-13 February 2012. You may still be contacted should a position become available that matches your skills and experience.

WHAT TRAINING IS PROVIDED TO ME?

Training is not provided to all applicants. If it is required for the roster placement you are offered as a successful applicant, one of our recruitment team will be in contact with you to discuss any relevant training you may need to attend. Eg - Responsible Service of Alcohol (RSA) is required for all staff involved in the service of alcohol. If you have already completed this training you will need to supply a copy of your certificate.

Training will be provided by Hospitality Industry Training SA, 1st

Floor 107 O’Connell Street, North Adelaide, South Australia.

DO I NEED TO PAY FOR THE TRAINING? or DO I GET PAID TO ATTEND TRAINING?

No, training is provided free of charge. If you are a current Spotless employee and are required to attend RSA or Food Hygiene Training sessions you will be paid.

I HAVE RECEIVED AN OFFER OF ROSTER PLACEMENT – WHAT DO I NEED TO DO WITH IT?

Upon receiving your offer of roster placement, you will be required to confirm you are still available to work the allocated shifts. Your roster will provide clear information on how your roster needs to be confirmed.

If you are no longer able to work some or all of the allocated shifts, you must contact the Clipsal 500 Recruitment Team as soon as possible after receiving your roster placement.

DO YOU CONFIRM MY CONFIRMATION OF ROSTER?

NO – once you have received an offer of roster placement and confirmed your shifts as instructed, you will not receive another confirmation advice from us. We will only be in contact with you again should your shift or work area change.

IS IT NECESSARY TO ATTEND THE SAFETY INFORMATION SESSION PRE EVENT?

YES – it is strongly recommended that you attend this information session to learn about working for Spotless and the track environment. You can also collect your uniform. It is also an excellent opportunity to see the track as well as meeting your co workers and the management team.

I WANT TO FIND OUT MORE… Please download a copy of the Event Handbook available at www.employmentsolutions.com.au for comprehensive information about your employment with Spotless and the track environment or contact CLIPSAL 500 HOSPITALITY STAFF ENQUIRIES 1300 244 495.

Page 3: Application for Employment & Consent

Application for Employment & Consent Form ALL APPLICANTS MUST SUBMIT APPLICATION FORMS & RESUME (NO MORE THAN 3 PAGES) AT NOMINATED RECRUITMENT SESSION OR FORWARD TO : Clipsal 500 Staffing, Mission Australia – PO Box 272, Kilkenny SA 5009 Email: [email protected] or Fax: 08 8409 1099 P L E A S E P R I N T C L E A R L Y JS DB

ALL NEW APPLICATIONS TO SPOTLESS WILL BE PROCESSED THROUGH MISSION AUSTRALIA PLEASE CALL 1300 244 495 OR VISIT www.employmentsolutions.com.au FOR FURTHER INFORMATION

for all the latest news and up to date information about the Clipsal 500 race visit - www.clipsal500.com.au

JOB SEEKER ID - Do you have a JOB SEEKER ID: Mission Australia is a Job Services Australia provider

Yes No If Yes Provide Job Seeker ID _____________________________ Job Services Aust. provider ____________________________

Surname First Name

Address

Suburb State Postcode

Phone Mobile

Email

Date of Birth Due to Liquor Licensing Laws you must be over the age of 18 years to provide service in a retail bar or corporate box.

Legally Entitled to Work in Australia Are you a permanent resident of Australia? Yes No If No, you will be required to provide a valid visa

POSITION APPLIED FOR - Please number boxes in order of preference - only if you have relevant/proven experience

Corporate Boxes Retail Cash Handling Required Kitchens Stores Supervisor 40+ guests

Supervisor up to 40 guests

Waiting Staff – Advanced

Waiting Staff – Basic/Inter.

Waiting Staff – Carry 3 plates

Barista (coffee)

Bar Supervisor 10+ Staff

Bar/Beer Van Supervisor

Coke/Milk Van Supervisor

Bar Assistant

Counter Assistant

Table Cleaner

Head Chef

Sous 2nd Chef

Production Chef

Qualified Cook

BBQ/Grill Cook

Kitchen Hand Supervisor

Kitchen Hand

Stores Manager

General Hand/Runner

Night Fill Runner (6pm start)

Licences Drivers Forklift

Scissor Lift Reach Truck

Truck Licence – type ____________

I am school student with limited hospitality experience or employment history I am aware my application is limited to those positions that do not require the service of alcohol, and I have parent/guardian permission to apply for work

Please state the minimum shift you will accept 3 hrs 4 hrs 5 hrs 6 hrs 8 hrs Any shift available

AVAILABILITY - Please enter your available times – shifts are between 7am – 10pm Are you a university student? No Full-time Part-time External – will this effect your work availability No Yes

Do you have any sporting commitments that will affect your work availability? Yes No If YES please state in your availability below

Pre Event Setup 13 – 29 February 2012 limited positions

Race Day 1 Thursday 1 March 2012

Race Day 2 Friday 2 March 2012

Race Day 3 Saturday 3 March 2012

Race Day 4 Sunday 4 March 2012

Post Event Packup 5 – 16 March 2012 limited positions

TRAINING - Please ATTACH COPY OF CERTIFICATE if not completed with Spotless Name of Qualification Date Where? - Training Institution/Organisation Name

Responsible Person Badge (Alcohol) Yes No

Provide Responsible Service of Alcohol Yes No

Follow Workplace Hygiene Procedures Yes No

Certificate in Hospitality I, II, III or IV Yes No

CURRENT/LAST EMPLOYER Name of Company/Organisation

Your Position Held

Length of Service Reason for Leaving

Describe Duties & Responsibilities

HOW DID YOU HEAR ABOUT CLIPSAL 500 RECRUITMENT? Select One The Advertiser Spotless/Mission/Clipsal 500 – Website (circle one) Job Services Australia (name) __________________

Messenger Newspaper Career One / Seek (circle one) University Career Department

Other – please state

Page 1 of 3 PTO sign and consent

Page 4: Application for Employment & Consent

PREVIOUS EMPLOYMENT

Name From To Last Position Held Reason for Leaving

Have you worked for Spotless or any of its subsidiary businesses before?

Yes No

If yes, where & when

REFEREES – Note: referee must be a person who candidate has reported to in the past 5 years Name Position Company Contact Number

GENERAL Pre-Employment Health Assessment Will you agree to undergo a pre-employment health assessment specific for the requirements of the position as a part of the selection process?

Yes No Please complete the enclosed Pre-Employment Medical Questionnaire.

Security Clearance, Drug and Alcohol Tests Some roles require testing for security and safety purposes either prior to commencing employment or during employment. Are you prepared to undertake a Security, Drug or Alcohol test?

Yes No

Drivers Licence Some roles are required to have current drivers licence to perform the role. Do you have a current Australian Drivers Licence?

Yes No

CONSENT – Please read carefully before signing I understand that this form is an Application for Employment and its completion does not mean that I have been successful in the recruitment process, ie., it is no guarantee of employment. I certify that the information on this form is true and correct and I understand that the misrepresentation or omission of facts may be sufficient grounds for rejection of my application and/or termination of employment. I hereby authorise any of my former employers to furnish their records of my employment. I also acknowledge that all information supplied by myself may be used within other business units of Spotless Group of Companies. 1. For the purposes of this consent form, Spotless, staff@events and Mission Australia Employment Solutions will be known as the Agencies. 2. Acknowledge that the Agencies will collect information (including personal information) about me for employment purposes, including

consideration of my employment application in the recruitment process. 3. Consent to the Agencies taking a photograph of me or alternatively bring a current photo of myself to the interview. This will be used in

connection with my employment application. 4. Consent to the Agencies checking any referees provided or unsolicited in relation to my employment application. (Current employers

excluded). 5. Consent to the Agencies verifying my qualifications with all relevant education institutions. 6. Consent to undertaking a health assessment relevant to my employment application. 7. Consent to the Agencies if it requires obtaining a security check relevant to my employment application with law enforcement agencies

including the Police and Australian Customs. 8. Consent to all the information described above being maintained in the Agencies records for employment purposes. 9. Consent to all of the information described above, including any testing, being disclosed to the Agencies for consideration in the recruitment

process.

Candidate Full Name

Sign: Date:

Page 2 of 3 Please sign consent above

Page 5: Application for Employment & Consent

SA.BRPAY - NEW EMPLOYEE – PARTIAL SETUP Clipsal 500, 2012 – SSA-Spotless Services Aust. Ltd

Hospitality Services, South Australia

1 SURNAME FIRST NAME MIDDLE NAME

Street No. Street Name Suburb State Post Code

Employee Phone No. Home Mobile

Employee Date of Birth:

OFFICE USE ONLY - Employee Number:

Commencement Date

Sex (Circle One)

Work Type

Home Branch

Award Code Classification Code

Employee Type

/ / F / M MF 0822 0823

503 FB2 COOK4

1 - CASUAL

Emergency Contact:

Name

Number

BANK DETAILS

Bank Name (in full):

Bank Address:

BSB Number (max 6 digits):

Persons name bank account is in:

Account Number (max 9 digits):

SUPERANNUATION:

Provide Superannuation Fund Name Superannuation Fund Member Number

If you do not have, or have not nominated a superannuation fund above, a Host Plus application will be created for you by Spotless. Please note for the purpose of this employment Spotless are unable to pay into personally managed superannuation funds.

EMPLOYEE AUTHORISATION:

Employee Signature: Date: 2012

SPOTLESS AUTHORISATION & PAYROLL INFORMATION:

Approved : Aaron Bond

Signature:

Date:

2012

Contact: 08 8354 8222 Email: [email protected]

Level 1 Level 2 Level 3 Level 3-1 Level 3-2 Level 4 Level 5 Level 6 Level 7

R-921 R-926 R-931 R-936 R-937 R-938 R-939 R-940 R-941

ATTACHMENT REMINDER CHECKLIST – I HAVE ATTACHED: A COMPLETED & SIGNED TAX DECLARATION YES

IF A NON AUSTRALIAN RESIDENT – COPY OF A VALID WORKING VISA YES A COMPLETED & SIGNED EMPLOYMENT MEDICAL QUESTIONNAIRE (EMQ) YES

A CURRENT RESUME OF NO MORE THAN 3 PAGES YES COPY OF TRAINING CERTIFICATE FOR HOSPITALITY, RESPONSIBLE SERVICE OF ALCOHOL OR OCCUPATIONAL HYGIENE YES

Page 3 of 3 Please sign Employee Authorisation

Page 6: Application for Employment & Consent

EMPLOYMENT MEDICAL QUESTIONNAIRE 2012 Clipsal 500 Adelaide

The aim of this Employment Medical (“EMQ”) Questionnaire is to ensure that applicants physical and other related abilities are matched to the medical and fitness standards for the particular duties of a job. Employment Medical Questionnaires (EMQ’s), are necessary to determine that:

There is no risk of aggravating a pre-existing medical condition

The applicant is able to productively carry out the duties of the position safely

The applicant should not, because of a medical condition, increase risk to other workers, equipment, products or the general public.

CONFIDENTIALITY The Employment Medical Questionnaire is treated as a confidential document and access is limited to a ‘need to know’ basis. In the event of you being employed, Spotless will retain this form on a confidential file and reserve the right to refer to the information in the event of an accident, sickness, injury or claim for worker’s compensation. The information may also be used for other purposes, if so required by law.

IMPORTANT NOTICE To assist Spotless in assessing your medical fitness for employment, you must answer the questions contained in this questionnaire truthfully and to the best of your knowledge.

Failure to disclose any relevant matter relating to your health may result in your not being employed by the employer and, if already employed by the

employer, your employment may be affected and rights to workplace compensation compromised.

Surname: Given Name:

Address:

Post Code: State:

Telephone: (H) Mobile:

Position Applying for:

Age: Date of Birth Sex: M/F

HAVE YOU LOST ANY TIME FROM WORK IN THE LAST 12 MONTHS DUE TO ILLNESS OR INJURY? YES NO

If yes, please state for what reasons:

WILL YOU BE PREGNANT DURING THE EVENT WORK PERIOD? YES NO

If yes, please state how many months advanced do you expect your pregnancy to be for the event Months

ARE YOU CURRENTLY TAKING, OR IN THE PAST TWO YEARS HAVE TAKEN ANY MEDICATION? YES NO

If yes, please state:

DO YOU HAVE ANY KNOWN ALLERGIES?: YES NO

If yes, please state:

ARE YOU TAKING OR DO YOU NEED TO TAKE ANY MEDICATIONS FOR THE KNOWN ALLERGY?: YES NO

If yes, please state:

ANY ADDITIONAL INFORMATION IN RELATION TO ALLERGY?

HOW MANY HOURS AT A TIME CAN YOU STAND AND/OR WALK FOR AT A TIME? Please circle answer

Less than 1 hour at a time / 1-2 hours / 2-4 hours 4-6 hours / 6-8 hours / more than 8 hours at a time

LIFESTYLE HABITS

Are you a current smoker? YES NO Average per day: Type: Cigarettes / Cigar / Pipe

If not a current smoker have you ever smoked? YES NO If YES, when did you give up?

For how long did you smoke (years)? Average per day: Type: Cigarettes / Cigar / Pipe

Do you drink alcohol? YES NO What type?: Average per week? Glasses

Are you involved in sporting activities or hobbies? If YES, please list:

DO YOU HAVE ANY CONDITION OR PROBLEM THAT MAY IMPACT UPON YOUR ABILITY TO PERFORM YOUR JOB? If YES, please provide details below

YES NO

VACCINATIONS – Have you been vaccinated against: Hepatitis A YES NO / Hepatitis B YES NO / Tetanus YES NO

CURRENT MEDICAL PRACTITIONER/FAMILY DOCTOR

Clinic Name and Address

Telephone: Doctor:

PTO FOR FURTHER DETAILS & SIGN DECLARATION

Page 7: Application for Employment & Consent

DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING CONDITIONS? IF YES FOR ANY QUESTIONS YOU WILL NEED TO PROVIDE FURTHER

DETAILS IN THE COMMENTS COLUMNS PROVIDED. IF YOU NEED MORE SPACE THAN IS PROVIDED PLEASE PROVIDE AS AN ATTACHMENT.

CONDITION Please tick YES NO DURATIONS & DATES OF CONDITION CURRENT STATUS

1 Asthma, Bronchitis, Pleurisy, Coughing, Breathlessness, Tuberculosis (TB) or other lung complaints

2 Coughing up blood

3 Hay fever, sinusitis, severe headaches

4 Heart disease, heart attack, heart complaint

5 Chest pain

6 Blood pressure, heart irregularities, rheumatic fever

7 Anaemia, bleeding disorders, other disorders of the blood

8 Vascular or other blood vessel disorders

9 Arthritis

10 Bone or joint problems

11 Broken bones, fractures or dislocations

12 Any joint pain or injury

13 Muscle, tendon or ligament problems

14 Pains, aches, numbness or weakness in the neck, shoulders, arms, hands or fingers

15 Feet, ankle, knee problems

16 Strains or sprains

17 Back complaint / back injury

18 Gout

19 Hernia, rupture

20 Stomach or duodenal ulcers

21 Chronic indigestion

22 Intestinal or bowel trouble

23 Chronic constipation

24 Haemorrhoids

25 Vomiting blood

26 Passing blood in motions

27 Hepatitis

28 Diabetes, thyroid problems, gallbladder problems or other gland problems

29 Any skin conditions

30 Head injury

31 Epilepsy, fainting, fits, blackouts or dizzy spells

32 Chronic headaches or migraines

33 Vision problems that cannot be corrected by prescription glasses

34 Ear conditions, hearing loss, deafness or tinnitus (ringing in ears)

35 Nervous disorders, mental or psychiatric problems, depression

36 Any sporting, vehicle or work-related illness or injury

37 Have you worked in any noisy conditions

38 Have you worked in any dusty conditions

39 Do you have a fear of heights or confined spaces

40 Any other illness, injury, health condition or operation not mentioned:

DECLARATION - I hereby declare that: I have read and understood the conditions on this form

I understand that, if employed, the information I provide will be retained on my employee file and that the employer reserves the right to access and use the

information, in the event of an accident, injury, sickness or claim for workers’ compensation or for any other reasonable purposes, if so required by law.

I consent to Spotless and its medical representatives obtaining or exchanging further medical information from my treating doctors or other health practitioners,

if required for the purposes of this assessment.

My answers relating to my medical and employment history are true and complete to the best of my knowledge. Furthermore there is nothing else regarding my

health, wellbeing or ability to carry out the potential role which Spotless or its medical advisers may need to know to assess me for the position(s) I have

applied.

I am fully aware that if I fail to disclose any relevant mater relating to my health, which renders me incapable of properly fulfilling the duties of the position,

the employer may not employ me and if already employed by the employer, the employer may not employ me.

I understand and agree that this report and any related health information provided may be supplied to Spotless and its medical advisors.

SIGN Full Name of Applicant Date: