Mercy Health and Aged Care Central Queensland Limited


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.

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?

PERSONAL DETAILS
Preferred Title:		Family Name*:
Given Name(s)*:		Preferred Name:

CONTACT DETAILS
No. & Street:		Suburb:
State/Territory:		Postcode:
Mailing Address:		Email:*
Preferred Phone Contact:*		Work Phone:
		Can we contact you at work?	Yes No

CITIZENSHIP STATUS
Are you an Australian Citizen? *	Yes No
Do you have permission to work in Australia?	Yes No `

EDUCATION AND QUALIFICATIONS
Secondary Education
Grade Completed:		Name of Institution:

Tertiary Education (if applicable)
If more than two (2) please indicate those of most relevance to the sought position
1. Year study commenced:		Year study completed:
Name of Institution (e.g. TAFE, University):		Certificate/Qualification:
2. Year study commenced:		Year study completed:
Name of Institution (e.g. TAFE, University):		Certificate/Qualification:

Have your qualifications been recognised to enable you to work in Australia?		Yes No
If Yes, please provide details:

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)			Yes No

GENERAL

Do you have a current Australian Driver's Licence?		Yes No
Do you have a current Blue Card? *		Yes No
What is the expiry date of your Blue Card?
Have you been previously engaged by Mercy Health and Aged Care Central Queensland Limited? *		Yes No
If Yes: Period of Employment (years): 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). *			Yes No

EMPLOYMENT HISTORY

1. Employer:		Position:
Employment Period (years):		to
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:

2. Employer:		Position:
Employment Period (years):		to
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 (years):		to
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 provide the identity of your primary referee.
Referee Name:*		Phone Contact:*
Professional Relationship:*

RESUME/CURRICULUM VITAE
Select your resume/curriculum vitae. PDF or Microsoft Word formats are preferred. If you have issues sending the file using this application form, please email it to employment@mercycq.com.

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: