Armadale Sitters Employment Application - Step 1

Name :

Miss Mr Mrs Ms Other

Date of Birth : Applicants must be over 19 years of age

- Day - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - Month - January February March April May June July August September October November December - Year - 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933

Marital Status :

Single Defacto Married Divorced Widowed

Do you have children?

What are their ages?

Do you have grandchildren?

What are their ages?

Do you have a Driver's License? Applicants must have a Driver's License

No Manual Automatic

Do you have your own car? No Yes Applicants must have a car

Will you be able to provide a :

Photo Doctor's Letter Police Check First Aid Certificate

Have you ever been charged or convicted of a criminal offence?

No Yes- Details :

How would others describe you?

Address :

Street No Street Name
Suburb State ACTNSWNTQLDSATASVICWA Post Code

Phone :

	Home		Work
	Other		Fax
	Mobile
	Do you have voice mail?
	Should we be discreet when contacting you at work?

Email :

Are you a smoker? No Yes

Have you had a Work Care Claim? No Yes

Details:

Do you have any Back Problems? No Yes

Details:

Do you have, or have you had any of the following conditions :

Diabetes Epilepsy Heart Problems Mental Illness
Other conditions that an employee should be aware of (please specify)