Application for Employment

Position Applying For __________________________ Location ____________________________

Personal Details (Must be filled in by applicant in handwriting. Please print)

First Name _______________________________ Surname ________________________________

Vaccination Status: Vaccinated YES | NO Vaccination Type ______________

Date of vaccination ______________ Booster received YES | NO

Residential Address _________________________________________________________________________

Phone Contact ___________________________ Email contact ______________________________________

Alternate phone contact ________________________ Name of contact _______________________________

Date of Birth ___________ Age ______ Gender M | F Martial Status ______________ Number of children _____

Age of Children ______________ Vaccinated YES | NO If no, are you willing to get the Vaccine YES | NO

Education
(Including University, further education establishments)

School/College/Tech/University From To Standards attained/Qualifications

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Other qualifications/skills applicable to the position

Describe qualifications/Skills Date and place achieved

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An Updated CV must be attached. Indicate if CV is attached. CV Attached YES / NO

If NO, be advised that your application will be considered INCOMPLETE until you submit a CV.

Employment History
(List most recent employer first/include all employment)
No contact will be made with your current employer until you have given specific permission at the interview.

Name of Employer _________________________ Position held/nature of work ____________________________

Period of employment. From ____________________ To ____________________

Reason for leaving __________________________________ Rate of Pay K _______________

Name of Employer ________________________ Position held/nature of work _____________________________

Period of employment. From ___________________ To ___________________

.
Reason for leaving __________________________________ Rate of Pay K ________________

Name of Employer ________________________ Position held/nature of work _____________________________

Period of employment. From __________________ To ___________________

.
Reason for leaving __________________________________ Rate of Pay K ________________

Name of Employer ________________________ Position held/nature of work _____________________________

Period of employment. From __________________ To ___________________

.
Reason for leaving __________________________________ Rate of Pay K ________________

Referees (please provide last employer and at least one previous employer)
No contact will be made with any of your referees until you have given specific permission at the interview.

Name …………………………………………. Title …………………….…………………………… Telephone ………………………….

Name …………………………………………. Title ……………………...……………………….… Telephone ………………………..…

Name …………………………………………. Title …………………………….…………………… Telephone …………………………. Page 02 /05

PEASE TICK APPROPRIATE BOX ALL QUESTIONS MUST BE ANSWERED, IF NOT APPLICABLE, INDICATE AS N/A

Were you previously employed in Brian Bell Home Centre, Trade Electrical or Chemicals? Yes No

If YES, indicate position and period of employment/ Indicate whether you were employed as casual or on full

time) _______________________________________________________________________________________

If your application is unsuccessful, would you like to be considered for another position? Yes No

Indicate other position(s) you would like to be considered for _________________________________________

Brian Bell operational requirement is Monday to Saturday work. Can you work on Saturdays? Yes No

If NO, indicate why? __________________________________________________________________________

You may be required to work Sundays/ Public Holidays / after hours. Are you comfortable with this? Yes No

If NO, indicate why? __________________________________________________________________________

Have you ever been convicted of a criminal offence? Yes No

If YES give brief details _________________________________________________________________________

Are you currently before the Courts on any matter? Yes No

If YES give brief details _________________________________________________________________________

Do you owe the banks/money lenders/loan sharks money in which they may be looking for you? Yes No

If YES give brief details__________________________________________________________________________

If you have a Driver’s License, indicate Class and Expiry Date

Are you able to provide your birth certificate and those of your dependents upon request? Yes No

If NO give brief details__________________________________________________________________________

Would you undergo a Police Clearance upon request? Yes No

If NO give brief details___________________________________________________________________________

Do you have an active bank account, if YES, give details? Yes No Bank/branch ________________________

Are you currently contributing to a Superannuation Fund? Yes No Membership # ____________

Do you know of any person currently employed by this Company? Yes No ___________________________

If YES give name, relationship to you and phone contact_____________________________________ Page 03/05
If you are offered a position, when is the earliest you could commence? _________________________________

Medical

Would you undergo a Pre-Employment Medical Check upon request? _______________________ Yes No

If NO give brief details__________________________________________________________________________

Have you ever suffered from an injury at work that required you to take time off? Yes No
If YES give brief details__________________________________________________________________________

Do you have any illness or injury that may prevent you from performing work? Yes No
If YES give brief details_________________________________________________________________________

Do you have any medical condition(s) that is not life threatening you wish to disclose? Yes No
If YES give brief details_________________________________________________________________________

Have you taken more than five days absence as a result of an illness/injury in the last 12 months? Yes No
If YES give brief details_________________________________________________________________________

Brian Bell operates a Staff Medical Scheme which is subsidized, would you consider joining? Yes No
If NO, give brief details_________________________________________________________________________

Do you smoke? Yes No Do you chew betel nut? Yes No

Do you use illicit drugs? Yes No

Personal interests
List any hobbies/sporting interests etc.
___________________________________________________________________________________________
___________________________________________________________________________________________

Declaration
I declare that the information provided above and/or below or as attached is to the best of my knowledge a True
and Correct record.

I consent to the company seeking verbal or written information on a confidential basis about me, from
representatives of my previous employers and/or referees, and I authorize the information sought to be used by
the Company for the purpose of ascertaining my suitability for the position for which I am applying.
I further accept that the Company may conduct credit and criminal record checks through the appropriate
authorities.
I understand that the information received by the Company is supplied in confidence as evaluative material and
will not be disclosed to me.

I understand that by completing this application, there is no guarantee that I will be contacted nor considered for
an interview and the Company has no obligation in providing a written response to my expression of interest.
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I understand that all supporting information or attachment that I provide will now become the property of the
Company and they may use it for whatever purpose that suits them, and I understand that this attachment or
information may not be returned to me.

Applicant’s signature ___________________________________ Date ______________________________

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