This form is to be completed whenapplying for employment atLord Somers Camp and Power House (LSC & PH).

Privacy Notice:

The collection and processing of the information on this form is in accordance with relevant legislation, regulations made from time to time, any ministerial orders, instructions and policies issued by LSC & PH and any applicable federal award and/or agreement. LSC & PH may disclose some of your personal information, as applicable, to outside organisations /bodies that require this information to assist with providing employment services such as taxation and superannuation. You are able to request access to the personal information that we hold about you, and to request that it be corrected. The LSC & PH privacy policy can be found on the LSC & PH website.

  1. Completing the Form Personal details

Personal details must be completed in full. Your first given name must be entered as shown on your birth certificate unless you have changed your first name officially. Please do not use shortened names.

Working with Children Check or Equivalent Police Criminal Records Check

Before employment can commence you must have a valid, current Working With Children Check card (or equivalent such as a Current, valid VIT registration with a current Police Criminal Records Check. Working Children Check cards must be with an “E” (employee). A “V” (volunteer) type card is not accepted. You may also be required to undertake a criminal records check.

Pre-employment medical requirements

Any future offer of employment will be subject to you satisfying the LSC & PH pre-employment medical requirements.

  1. Employment Documentation

Certified copies of any of the following documentation may be requested of short listed candidates. The information provided will form the basis of the employee’s personnel file held at the LSC & PH Office.

  1. Evidence of Date of Birth (required document)

A copy of your birth certificate, extract of birth entry, passport, certificate of naturalization or certificate of citizenship. If your name is different to what is recorded on the document above, evidence which shows both your current and former names is required e.g. copy of certificate of marriage, certificate of registration of change of name.

  1. Evidence of permanent resident status or current visa status (required)

If you are not an Australian or New Zealand citizen, a copy of the relevant pages from your passport showing a stamp which confirms your right to permanent residence in Australia. Your name must appear on the copy. If you are not a permanent resident,evidence of your current visa status demonstrating that you have sufficient work rights to undertake the position at the school.

  1. Pre-employment medical requirements

A completed a pre-employment health declaration.

  1. Evidence of Working With Children Check or Equivalent (eg. Victorian Institute of Teaching Card)
  1. Evidence of academic qualifications
  • Copies of academic records (official transcripts) of all subjects completed in relevant qualifications obtained.

Position Title
  1. Personal Details (Please use BLOCK LETTERS)

Family Name: / Given Name(s):
Date of Birth: / ………./………/…………. / Gender: /  Male /  Female / Other/Prefer not to say
If your name has changed, indicate your original family name:
Are you an Australian Citizen?YesNoIf NO, please provide evidence of permanent residence status or visa documentation.
Address & Contact Information
Number/Street:...... Suburb/Town:......
State:...... Postcode:...... Preferred Telephone No:...... Alternative No:......
Email Address......
  1. Previous Relevant Employment Experience

Experience
EmployerDates Role
...... ___/___/___ to ___/___/___ …………………………………………………………………………………………………………………………………………………………
...... ___/___/___ to ___/___/___ ………………………………………………………………………………………………………………………………………………………….
...... ___/___/___ to ___/___/___ …………………………………………………………………………………………………………………………………………………………….
...... ___/___/___ to ___/___/___ ……………………………………………………………………………………………………………………………………………………………
...... ___/___/___ to___/___/___ ……………………………………………………………………………………………………………………………………………………………
  1. Qualifications Relevant for this Position

Name of CourseName of InstitutionCompletion DateCourse Length
First Qualification...... Years
Second Qualification...... Years
Third Qualification...... Years
Fourth Qualification...... Years
  1. Other Relevant Experience / Training /Memberships& Affiliations

OrganisationDates Experience / Service / Membership
...... ___/___/___ to ___/___/___ …………………………………………………………………………………………………………………………………………………………
...... ___/___/___ to ___/___/___ ………………………………………………………………………………………………………………………………………………………….
...... ___/___/___ to ___/___/___ …………………………………………………………………………………………………………………………………………………………….
...... ___/___/___ to ___/___/___ ……………………………………………………………………………………………………………………………………………………………
...... ___/___/___ to___/___/___ ……………………………………………………………………………………………………………………………………………………………
  1. Working With Children Check or Equivalent (or VIT Registration)

Do you have a current Employee (E) type Working with Children Check (WWC Check) Card?No Yes
If YES, provide your WWCCheckCard Number:...... and attach a certified copy of your card to this form
Do you have a current Victorian Institute of Teachers Registration?......  No Yes
If YES, provide your VIT Registration Number:...... and attach a certified copy of your card to this form
If you answered NO to both of the above you will need to commence application for a Working With Children Check including a Police Criminal Records Check immediately upon notification of being shortlisted for interview.
  1. Additional Information

If you answer YES to any of these questions, provide relevant details including dates on an attached sheet
A. Have any of your periods of service with any employer ceased due to ill health of any kind?...... Yes No
B. Were you ever the subject of disciplinary action?...... Yes No
C. Have you ever been convicted of a crime? ......  YesNo
D. Do you currently have any outstanding criminal matters before the court?...... Yes No
  1. Referees

The selection panel will expect to contact your current or most recent employer at some point in the recruitment process.
First Referee Second Referee
Name of Referee …………………………………………..………….………… ……………………………………………………………………….
Organisation...... ………………………….. ...…………………………………………………………….…..
Position...... ………………………….. ...………………………………………………………………..
Contact Phone………………………………………………………………...... ………………………………………………………………..
Contact email...... …………………………... ..………………………………………………………………..
Experience with /
Knowledge of ……………………………………………………………….. …………………………………………………………………….
applicant: ……………………………………………………………..… …………………………………………………………………….
……………………………………………………………….. ……………………………………………………………………
  1. Declaration

I declare that the information I have provided is true and correct.
Signature of Applicant...... Date ___/___/_____

Employment in Lord Somers Camp and Power House – Validation of Personal InformationPage 1