Application - cover form

I am applying for:

Position Title:
Classification:
Division:
Location:

Personal details:

Title (circle / delete as appropriate): / Mr / Mrs / Ms / Miss / Dr / Other
Given name(s):
Family name:
Street address:
State:
Email address:
Preferred contact number (include area code):
Are you an Australian citizen?
(Note: you must hold Australian citizenship to be eligible) / Yes / No
Are you willing to undergo a police check as part of the pre-employment screening process? (circle / delete as appropriate): / Yes / No
Are you willing to undergo a health check (may be required) as part of the pre-employment screening process? (circle / delete as appropriate): / Yes / No
What primarily attracted you to this position?
Have you received a redundancy from an Australian Public Service Agency or the Australian Parliamentary Service?
If yes, from which Agency did you receive the redundancy?
When does your calculated redundancy benefit period end:* / Yes / No
Agency name:
dd / mm / yyyy

*if your redundancy benefit period does not expire within two months from the closing date of this advertised vacancy, you may be ineligible to apply for this employment opportunity.

Current employment details:

Current employer:
Period of employment:
Position title:
Current salary:
Current employment status (e.g. ongoing / non-ongoing / full-time / part-time):
(ongoing means permanent employee and non-ongoing means temporary employee)
If you are an APS employee: / AGS number:
Substantive level:
Have you ever been found to have breached the APS Code of Conduct as set out in section 13 of the Public Service Act 1999 where this breach has resulted in a sanction being applied(only applicable for APS employees)?
Agency in which you were employed: / Yes / No
dd / mm / yyyy
Agency name:

Nominated referee details

Referee 1 / Name:
Workplace:
Contact phone number:
Business relationship:
Referee 2 / Name:
Workplace:
Contact phone number:
Business relationship:

Diversity information

This information enables us to provide appropriate facilities for people during interview. It is also used for statistical purposes and is not used in any way as part of the assessment for the position.

Gender:
Are you of Australian Aboriginal or Torres Strait Islander descent, or do you identify as Australian Aboriginal or Torres Strait Islander and are accepted as an Aboriginal or Torres Strait Islander person in the community in which you live, or have lived? / Yes / No
Do you have a disability and/or medical condition which may have an impact on your ability to carry out the inherent requirements of the role for which you have applied? / Yes / No
What is the first language used in your home, if other than English?

By submitting this form, I certify that the statements made by me and any supporting documentation are true and complete at the time of submission. I understand and agree that any false or misleading statements made in my application may disqualify me from employment or result in dismissal.I consent to the Australian Aged Care Quality Agency conducting any pre-employment checks, if required.

Signature:

Full name: ______

Date:dd / mm / yyyy

(By lodging your application via email, having typed your name here and sent from an address with the same name included in the address, you are considered to have “signed” and therefore agree to this statement).

1 | Page