Mercy Health and Aged Care Central Queensland Limited

EDUCATION AND QUALIFICATIONS

Secondary Education

Grade Completed:

Name of Institution:

Tertiary Education (if applicable)

1. Commencement of Study (year):

Completion of Study (year):

Name of Institution (e.g. TAFE, University):

Certificate/Qualification:

2. Commencement of Study (year):

Completion of Study (year):

Name of Institution (e.g. TAFE, University):

Certificate/Qualification:

If more than two (2) please indicate those of most relevance to the sought position

Have your qualifications been recognised to enable you to work in Australia?

Yes No

If Yes, please provide detail:

Position you are applying for*
Facility*
How were you referred to Mercy Health and Aged Care Central Queensland Limited?
When are you able to commence employment?

CONTACT DETAILS
No. & Street:		Suburb:
State/Territory:		Postcode:
Mailing Address:		Email:*
Preferred Phone Contact:*		Can we contact you on this number please type YES or NO into this feild *

Do you have a current Australian Driver's Licence?	Yes No
Do you have a current Blue Card? If YES please type in the expiry date, if NO please type NO. *
Have you been previously engaged by Mercy Health and Aged Care Central Queensland Limited? Type YES or NO. *
If Yes: Period of Employment (year): to
Position:		Reporting Authority:
Have you been convicted of a criminal offence by a court of law? If "YES", please give details of the offence(s) and dates of conviction and confinement (if applicable) if NO type NO: *

1. Employer:		Position:
Employment Period (dd/mm/yy):		to (dd/mm/yy)
Primary role responsibilities:		Employer Address:
Reporting to: (name)		(position)
Can we contact this person to conduct a telephone reference check? Yes No
If "YES", please provide telephone contact details:
Reason for leaving:


Thank you for seeking employment with Mercy Health and Aged Care Central Queensland Limited. Please complete each section of the Application For Employment Form to the best of your knowledge providing as much detail as possible.

CITIZENSHIP STATUS
Are you an Australian Citizen? please type YES or NO into this feild *
Do you have permission to work in Australia? please type YES or NO into this feild *

HEALTH
Do you have a physical or psychological condition(s) which may impair your capacity to fully perform the role you are applying for? If "YES", please provide details of condition(s) and impairment(s) if No type NO: *

2. Employer:		Position:
Employment Period (dd/mm/yy):		to (dd/mm/yy)
Primary role responsibilities:		Employer Address:
Reporting to: (name)		(position)
Can we contact this person to conduct a telephone reference check? Yes No
If "YES", please provide telephone contact details:
Reason for leaving:

3. Employer:		Position:
Employment Period (dd/mm/yy):		to (dd/mm/yy)
Primary role responsibilities:		Employer Address:
Reporting to: (name)		(position)
Can we contact this person to conduct a telephone reference check? Yes No
If "YES", please provide telephone contact details:
Reason for leaving:
PRIMARY REFEREE
(Telephone reference checks may be conducted on all applications for the purposes of shortlisting. Your Resume/Cirriculum vitae must include at least two (2) referees). Please disclose the identity of your primary referee.

DECLARATION
I confirm that the knowledge declared in my application is true and correct to the best of my knowledge, and I authorise Mercy Health and Aged Care Central Queensland Limited to contact referees and make whatever enquiries necessary in support of my application. I acknowledge that if I have provided false or misleading information in my application for employment I may be disqualified or subject to immediate dismissal if successfully appointed. *All information listed above I declare to be true and correct, if this is correct type YES into the field
I have submitted my resume/curriculum vitae via email to employment@mercycq.com? * Please type YES or NO into this feild.