Register

Surname

Given Name/Names

Title (optional)

Date of Birth

Address

Suburb Post Code

Phone (Home)

Phone (Mobile)

Email

Tax File Number

Occupation

Position Sought

Salary ExpectationsPer AnnumPer Hour

Work Type Permanent Temporary

 Part_time Executive

Secondary Level Attained

Tertiary  Complete

Post-tertiary  Complete

Other  Complete

Company 1

Job Title

Description of Duties

You may be placed in an assignment requiring physical labour, heavy lifting and strenuous activity. Lloyd Philips Group reserves the right to request that you provide a current medical certificate at your cost prior to placing you in assignments. LLOYD PHILIPS GROUP requests that you disclose all pre-existing injuries and diseases that you are aware of and which could reasonably be effected by the nature of the work you will be expected to undertake. You are asked to make this disclosure in accordance with Section 82(7) of the Accident Compensation Act 1985. Please note that any non-disclosure of injuries or the making of a false or misleading disclosure could mean that, if, during the course of your employment you sustain any recurrence, aggravation, acceleration, exacerbation or deterioration of the pre-existing injury or disease, you may have no entitlement to compensation under Secion s82(8) of the Accident Compensation Act 1985.

 I do have a pre-existing injury or disease that could be affected by the nature of the employment I may be offered.

 I do not have a pre-existing injury or disease that could be affected by the nature of the employment I may be offered.

If you do have a pre-existing injury or disease please provide details.

Please tick if yes or no:

Have you ever had trouble wearing personal safety equipment? Yes No

Are you currently being treated by a doctor for any illness or condition? Yes No

Are you currently taking any medication or drugs? Yes No

Are you allergic to anything? Yes No

Have you ever spent time in hospital as a patient? Yes No

Have you ever broken or fractured any bones? Yes No

Have you in the last 5 years lost time from work because of illness or injury? Yes No

Have you ever had a supposed disease or injury resulting from work? Yes No

Have you ever suffered with back or neck pain? Yes No

Have you ever had a back X-ray? Yes No

Do you suffer from, or have you ever suffered from RSI, occupational overuse syndrome, tennis elbow or tenosynovitis? Yes No