DUBBO NSW ALBANY WA

Lot 11 Yarrandale Road 520 Settlement Road

Dubbo NSW 2830 Narrikup WA 6326
Locked Bag 10 PO Box 680
Phone: 02 6801 3100 Phone: 08 9892 4000
Fax: 02 6884 2965 Fax: 08 9892 4080
For Office Use Only
JOB APPLICATIONS DEPARTMENT MEDICAL & INTERVIEW
Received / /  HARV  BYPR  Drug Screening
Phoned / /  HFAB  CLEN  Medical Form
Interview / :  CFAB  MAIN  Hearing Booth
Letter Sent?  Yes  No  LOUT  GIFT  Interview Summary
Induction / /  SKIN  STAF  Q-Vax Policy
Restarter?  Yes  No Notes: Notes:

APPLICANT TO COMPLETE THE FOLLOWNG (PLEASE ANSWER ALL QUESTIONS)

How did you find out about employment at Fletcher International Exports? (Please tick one or more)

 Word of Mouth  Newspaper  Job Service Provider (e.g. Joblink)

 Social Media  Company Website  Career/Industry Expo
 Online Advertisement  Other ______________________________________________________

EMPLOYMENT SOUGHT

 Full Time (40 Hours per Week)  Casual (up to 40 Hours per Week)  Part Time
What is the earliest date that you are available to start?:  ASAP or  Date ___________________

SECTION A | PERSONAL DETAILS

FIRST NAME: _________________________________ LAST NAME __________________________________

PREFERRED NAME _____________________________ GENDER:  Male  Female  Your own description:
DATE OF BIRTH: ________________________________ _____________________________________________
ADDRESS: ____________________________________
CONTACT NUMBERS
_____________________________________________
HOME: _____________________________________
SUBURB/TOWN: _______________________________
MOBILE: _____________________________________
POST CODE: _______________________________
EMAIL ADDRESS: ______________________________________________________________________________

THE FOLLOWING ARE CONDITIONS OF EMPLOYMENT AND REQUIRED AS PART OF OUR APPLICATION PROCESS
Do you agree to undergo a medical check by the Company?  Yes  No

Do you agree to submit to a urinary and/or oral drug screening?  Yes  No

Do you agree to be vaccinated for Q-Fever if offered employment?  Yes  No

Please ensure you have completed your application in full. We reserve the right to reject
any applications that are not completed in full.
CULTURE, COMMUNICATION AND LANGUAGE

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COUNTRY OF BIRTH: ______________________________ BIRTH TOWN: _________________________
 Australian Citizen or Permanent Resident
CITIZENSHIP STATUS
 Other – Please state Visa type/number ______________________________________
Please attach a copy of your Australian Birth Certificate/Australian Driver Licence OR Passport and Visa
HOW LONG HAVE YOU LIVED IN AUSTRALIA? ______________________________________________________

The following questions enable us to fulfill our statutory reporting obligations:

 Yes, Aboriginal
 Yes, Torres Strait Islander
ARE YOU OF ABORIGINAL OR TORRES STRAIT ISLAND DESCENT?
 Yes, both
 No, neither
DO YOU SPEAK A LANGUAGE OTHER THAN ENGLISH AT HOME?  No, English only
If more than one language, indicate the one that is spoken most often  Yes __________________________
 No, English only
DO YOU REQUIRE TRANSLATED DOCUMENTS FOR COMMUNICATION?
 Yes, as above
DO YOU IDENTIFY AS HAVING A DISIBILITY?  Yes
If yes, you may be required to provide us with further information  No
DO YOU REQUIRE ANY EXTRA ASSISTANCE FOR COMMUNICATION?  Yes
If yes, you may be required to provide us with further information  No

NEXT OF KIN | EMERGENCY CONTACT DETAILS

CONTACT (FULL) NAME: _______________________________________________________________________

RELATIONSHIP TO YOU:  Family  Friend  Partner CONTACT NUMBER ______________________

SECTION B | EDUCATION AND TRAINING

HIGHEST SCHOOL YEAR COMPLETED  Year 12  Year 11  Year 10  Year 9  Year 8  Year 7 or below
HAVE YOU ATTACHED A CURRENT RESUME TO THIS APPLICATION?  Yes
If yes, you are not required to complete Section B  No

Name of School/College/University Period Studied Course Studied

-
-
-
Trades or Professional Qualifications Attained

SECTION C | PERSONAL

ARE YOU CURRENTLY REGISTERED AS UNEMPLOYED?  Yes  No

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If YES, who is your Job Active Provider?
 Sureway  Joblink  Best Employment  Skill Hire WA  Max Employment  Other ___________________________
Please provide Jobseeker ID: __________________________

ARE THERE ANY RESTRICTIONS ON YOU WORKING OVERTIME OR SHIFT WORK?  Yes  No

DO YOU HAVE EXPERIENCE IN THE USE OF A KNIFE IN A WORKPLACE?  Yes  No

HAVE YOU WORKED IN AN ABATTOIR BEFORE?  Yes  No
If YES, please provide details below
Location: _____________________________________ When?  Last 12 Months  1 – 4 Years Ago  4+ Years
Job(s) performed: ______________________________________________________________________________

HAVE YOU EVER PREVIOUSLY WORKED FOR THE FLETCHER GROUP?  Yes  No
If YES, what Department? ____________________________________ When? ___________________________

HAVE YOU HAD ANY RELEVANT CRIMINAL CONVICTIONS?  Yes  No

If YES, we ask that you please provide relevant information below. Your response will be treated as strictly confidential. Please
note: failure to disclose relevant criminal convictions at this time may result in dismissal if you are offered employment.
_____________________________________________________________________________________________

_____________________________________________________________________________________________

SECTION D | EMPLOYMENT HISTORY (Last 3 Employers)

IS THIS YOUR FIRST JOB?  Yes  No

HAVE YOU ATTACHED A CURRENT RESUME TO THIS APPLICATION?  Yes  No
If you have attached a current resume, you are not required to complete Section D

EMPLOYER NAME PERIOD EMPLOYED

POSITION HELD CONTACT NUMBER

MAIN DUTIES AND

RESPONSIBILITIES

EMPLOYER NAME PERIOD EMPLOYED

POSITION HELD CONTACT NUMBER

MAIN DUTIES AND

RESPONSIBILITIES

EMPLOYER NAME PERIOD EMPLOYED

POSITION HELD CONTACT NUMBER

MAIN DUTIES AND

RESPONSIBILITIES
SECTION E | WORK HEALTH AND SAFETY & WORKERS COMPENSATION
HAVE YOU EVER RECEIVED OR ARE YOU CURRENTLY RECEIVING WORKERS COMPENSATION?  Yes  No

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This information is for insurance purposes only, and will not affect your application.
If YES to above, please complete the following details (provide attachments if required)
Name of Employer: _____________________________________________________________________________
Name of Insurer: _____________________________________________________________________________
Type of Injury: _____________________________________________________________________________
IN ORDER TO HELP THE COMPANY MEET ITS OBLIGATIONS UNDER CURRENT WORK HEALTH AND SAFETY
LEGISLATION, PLEASE TELL US IF YOU HAVE ANY CONDITIONS WHICH MAY:
(a) Interfere with your performance or ability to perform the inherent requirements of
 Yes  No
your role?
(b) Pose a risk to your health and safety?  Yes  No
(c) Pose a risk to the health and safety of others in the workplace?  Yes  No

If YES to any of the questions above, please provide us with further details. Please note: failure to disclose relevant information
at this time may result in dismissal if you are offered employment.

_____________________________________________________________________________________________
HAVE YOU EVER BEEN REFUSED LIFE INSURANCE, MILITARY SERVICE OR EMPLOYMENT DUE TO POOR HEALTH?
 No  Yes If yes, please specify ______________________________________________________________

YOUR HEALTH PROVIDER AND HISTORY

NAME OF TREATING DOCTOR/DOCTORS ___________________________________________________________
NAME OF PRACTICE & ADDRESS __________________________________________________________
HAVE YOU RECEIVED ANY MEDICAL TREATMENT IN THE PAST 5 YEARS WHICH IS RELEVANT
TO THE ROLE YOU ARE APPLYING FOR WITH THE COMPANY (E.G. STRAINS, FRACTURES ETC)?  Yes  No

If you answered YES, please provide us with further details. Please note: failure to disclose relevant information at this time
may result in dismissal if you are offered employment.
_____________________________________________________________________________________________
HAVE YOU HAD ANY OTHER SERIOUS ILLNESSES, OPERATIONS OR INJURIES?  Yes  No
If you answered YES, please provide details, including any work related injuries that were not compensated. Please note:
failure to disclose relevant information at this time may result in dismissal if you are offered employment.
_____________________________________________________________________________________________
_____________________________________________________________________________________________

HEIGHT (APPROX): ______________ cm WEIGHT (APPROX): ______________ kg

DO YOU WEAR GLASSES?  Always  Sometime  Never
WHAT IS THE GENERAL STATE OF YOUR HEARING?  Good  Average  Poor
HAVE YOU PREVIOUSLY WORKED IN A NOISY ENVIRONMENT?  Yes  No
HAS YOUR HEARING BEEN AFFECTED BY A PRIOR WORKPLACE?  Yes  No
WHAT IS YOUR APPROXIMATE ALCOHOL INTAKE?  Daily ____________  Weekly _____________
or
WHAT IS YOUR APPROXIMATE CIGARETTE INTAKE?  Daily ____________  Weekly _____________

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 or
DO YOU PARTICIPATE IN ANY HOBBIES OR SPORTS ON A REGULAR BASIS? (e.g. fishing, football, horse riding)
_____________________________________________________________________________________________
_____________________________________________________________________________________________

HAVE YOU EVER EXPERIENCED OR SUFFERED FROM THE FOLLOWING CONDITIONS? (Please tick if and specify if YES)
CONDITION DETAILS LAST AFFECTED
 Cellulitis  Eczema  Nervous Illness
 Psoriasis  Dermatitis  Mental Disorder
 Black outs  Migraines  Epilepsy/Seizures
 Stroke  Clots  Heart Complications
 Rheumatism  Arthritis  High Blood Pressure
 Hernia  Back Injury  Shoulder Trouble
 Scaiatica  Slipped Disc  Wrist Trouble
 Diabetes  Thyroid Issues  Kidney Issues
 Asthma  Hepatitis  Stomach Ulcer
 Tuberculosis  Hay Fever  Varicose Veins
 Chemical Allergy – please specify what chemical/s
 Medication Allergy – please specify what medication/s
 Other Allergy – please specify (e.g. peanuts)

Please note: failure to disclose relevant information at this time may result in dismissal if you are offered employment.

SECTION F | DECLARATION
By signing below, you confirm and agree to the following:
(a) You fully understand the contents of the document;
(b) You authorise Fletcher International Exports Pty Ltd to contact any of your previous employers or
references listed in relation to any and all information you have provided on this form;
(c) In the event of being offered employment with the Company, information regarding your
employment may be provided to any prospective employer/s following the end of your employment
with Fletcher International Exports;
(d) All the information you have provided on this form is true, accurate and complete;
(e) You fully understand that providing ANY false, inaccurate or incomplete information to Fletcher
International Exports Pty Ltd may result in your dismissal if you are offered employment.

I understand and accept all of the above:

NAME OF APPLICANT __________________________________________________________________________

SIGNATURE OF APPLICANT _____________________________________ DATE SIGNED _________________

 Photo Identification Attached

Fletcher International Exports Pty Ltd thanks you for your application. You will be advised if you are required to
undertake the next stage of recruitment process. All successful applicants are required to complete an initial
probationary period. Email your application to [email protected] or drop it in to our Gatehouse

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