Employment Status Permanent Fixed Term Department Substantive position title Level & increment Date appointed Section B Current employer Current position Date appointed REFEREES (please provide details of two referees) Name Organisation Contact Address Telephone Email Relationship Name Organisation Contact Address Telephone Relationship HEALTH To the best of your knowledge and belief do you have a medical condition, disability or injury which may preclude you from undertaking the duties of the position you are applying for? Yes No Applicants who have a health condition, disability or injury are invited to discuss its relevance or otherwise with the panel convenor. It is NOT a barrier to consideration of an application for employment. However, if it is likely to affect your work performance or could recur or be aggravated by the type of work for which you are applying you must disclose this information. WORKERS COMPENSATION Do you have a current or previous Workers Compensation Yes No If yes, please give details
Employment Status Permanent Fixed Term Department Substantive position title Level & increment Date appointed Section B Current employer Current position Date appointed REFEREES (please provide details of two referees) Name Organisation Contact Address Telephone Email Relationship Name Organisation Contact Address Telephone Relationship HEALTH To the best of your knowledge and belief do you have a medical condition, disability or injury which may preclude you from undertaking the duties of the position you are applying for? Yes No Applicants who have a health condition, disability or injury are invited to discuss its relevance or otherwise with the panel convenor. It is NOT a barrier to consideration of an application for employment. However, if it is likely to affect your work performance or could recur or be aggravated by the type of work for which you are applying you must disclose this information. WORKERS COMPENSATION Do you have a current or previous Workers Compensation Yes No If yes, please give details
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