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[page_title]
Step 1 of 7
14%
SECTION ONE - THE PERSONAL DETAILS
Name
*
First
Middle
Last
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Telephone :
*
Mobile :
*
Email Address :
Date of Birth :
*
Security License :
*
State Issued :
*
Expiry Date :
*
SECTION TWO - THE POSITION
What type of position are you applying for?
*
Crowd Control
Static Security
Cash In Transit
Mobile Patrols
Location
*
Availability:
*
Mon
Tue
Wed
Thurs
Fri
Sat
Sun
7 Days
When are you available to start?
*
What is the minimum number of hours that you are trying to achieve?
Do you have your own vehicle?
Yes
No
Are you willing to travel?
No
Yes 30mins and under
Yes 30mins to 1 hour
Yes 1 hour +
Do you have self defence techniques?
No
Yes
If yes, please explain:
Are you on a working visa?
*
Yes
No
If yes, please provide maximum number of hours permitted to work each fortnight :
Please outline your experience in the security industry:
Why are you suited to this role?
Please rate your confidence overall
1
2
3
4
5
6
7
8
9
10
Please rate your confidence in a conflict situation
1
2
3
4
5
6
7
8
9
10
SECTION THREE – FITNESS FOR WORK
Have you ever had or received treatment or medical advice for any of the following
1 Heart problems including heart attack, angina, heart surgery?
*
Yes
No
Please provide details
2 Lung problems including asthma, collapsed lung, chronic bronchitis, etc?
*
Yes
No
Please provide details
3 Seizures / fits / blackouts / epilepsy?
*
Yes
No
Please provide details
4 Panic attacks, stress, anxiety or depression?
*
Yes
No
Please provide details
5 Persistent headaches / migraines?
*
Yes
No
Please provide details
6 Alcohol dependence or substance abuse?
*
Yes
No
Please provide details
7 Have you ever had any operations?
*
Yes
No
Please provide details
8 Have you ever been hospitalised?
*
Yes
No
Please provide details
9 Any skin conditions i.e. eczema, dermatitis, skin rashes?
*
Yes
No
Please provide details
10 Any problems with your ears i.e. burst eardrums, problems equalising, loss of hearing?
*
Yes
No
Please provide details
11 Back problems including pain, sciatica, and/or whiplash?
*
Yes
No
Please provide details
12 Neck problems including pain and/or whiplash?
*
Yes
No
Please provide details
13 Any bone fractures or dislocations?
*
Yes
No
Please provide details
14 Pain in your shoulder, hip, knee, ankle, elbow or wrist?
*
Yes
No
Please provide details
15 Injury from a motor vehicle accident?
*
Yes
No
Please provide details
16 Any other medical condition which could increase your risk of injury at work or place others at risk?
*
Yes
No
Please provide details
Do any of the following apply to you?
17 Are you taking any medications of any type?
*
Yes
No
Please provide details
18 Do you take any illicit or recreational drugs?
*
Yes
No
Please provide details
19 Have you ever had a Workers Compensation claim or any work related illness or injury?
*
Yes
No
Please provide details
20 Do you have a current Workers Compensation claim?
*
Yes
No
Please provide details
21 Have you had any time off work in the past year (five days or more) due to any illness or injury?
*
Yes
No
Please provide details
22 Are you currently being treated by a Doctor, physiotherapist, or chiropractor for any injury or illness?
*
Yes
No
Please provide details
23 Have you ever been refused life/disability insurance, military service or employment?
*
Yes
No
Please provide details
Do you have any difficulty with any of the following activities?
24 Standing for three hours
*
Yes
No
Please provide details
25 Lifting or bending
*
Yes
No
Please provide details
SECTION FOUR - UPLOADS
Please be patient when uploading photos, especially from mobile devices, as these files may take a while to upload to the form...
Security License - Front
*
File upload
Security License - Back
*
File upload
SECTION FIVE - UPLOADS (CONT.)
Please be patient when uploading photos, especially from mobile devices, as these files may take a while to upload to the form...
First Aid Certificate
File upload
Responsible Service of Alcohol (RSA)
*
File upload
Responsible Service of Alcohol (RSA)
File upload
SECTION SIX - UPLOADS (CONT.)
Please be patient when uploading photos, especially from mobile devices, as these files may take a while to upload to the form...
Visa
*
File upload
Other
File upload
SECTION SEVEN – DECLARATION
I declare that each and every answer above is true and to the best of my knowledge and belief. I understand that if I am successful in gaining appointment, any false or misleading information may result in the termination of my employment.
Signature
*
Date
*
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