Application Form Application Form Step 1 of 9 11% Personal Details Name* First Last Address* Street Address City State Post code Email* Enter Email Confirm Email Phone* License details License Number* Type/Class* Expiry Date* State Issued* Number of years that you have driven a heavy vehicle* Conditions, if any, that applies to your licence* Demerit points left on licence at present* Any skills and/or training relevant to position: – i.e. BFM* Next of kin In case of emergency Name First Last Address Street Address City State Post code Email Phone Work History Employers Name Phone Address Street Address City State Post code Supervior Position held (title) Position held from Position held until Duties Reason for leaving Work History (if applicable) Employers Name Phone Address Street Address City State Post code Supervior Position held (title) Position held from Position held until Duties Reason for leaving References Please provide details of referees who can speak on your behalf. Reference Name 1 First Last Email Phone Reference details ------------------------------------PersonalWork Related Referee is a ------------------------------------FriendRelativeCo-WorkerSupervisorManagerCompany OwnerOther Reference Name 2 First Last Email Phone Reference details ------------------------------------PersonalWork Related Referee is a ------------------------------------FriendRelativeCo-WorkerSupervisorManagerCompany OwnerOther Authorization I authorize Hume Transport to contact the above. Occupational Health and Safety Have you been absent from work because of job related injury or physical disability?* ------------------------------------YesNo Please provide information (injury / disability & days absent from work) Do you have any current or pending claims in respect of workers compensation?* ------------------------------------YesNo Please provide details Have you been involved in any driving related accidents?* ------------------------------------YesNo Please provide details Have you ever had your licence cancelled?* ------------------------------------YesNo Date From Date Until Reason Pre-Employment Medical Questionnaire Are you currently being treated by a Doctor for any illness/injury/condition which may impact on your ability to perform the duties of the role you are applying for?* ------------------------------------YesNo Details of your condition: Are you currently taking any prescribed medications which may impair your ability to perform the duties of the role you are applying for?* ------------------------------------YesNo Details of your condition: Declaration Declaration* I declare that, to the best of my knowledge, the information given is true and correct. I understand that inaccurate, misleading or untrue statement or knowingly withheld information may result in termination of employment with this organisation. I understand that this application does not constitute and offer of employment. I understand that, in some case, police and credit checks will be required and I will be notified if this applies to this application. I understand that, if my application is successful, I will be required to complete a pre-employment medical, including a drug and alcohol test. I will also need to complete a full medical questionnaire.
