APPLICATION FOR EMPLOYMENT
Thank you for applying for employment with YellowBridge QLD. Your completion of all information will assist
us in considering your application. Please take the time to ensure you have answered all questions and,
where applicable, provided supporting documentation. Please also ensure you complete this form in your
own handwriting.
Position applied
for:
Disability Support Worker
PERSONAL PARTICULARS
Full
name:
D.O.B.:
_____/_____/_____
Address:
Phone:
Email:
GENERAL
Do you have a disability (physical, intellectual, medical or other) which would interfere with
your ability to do the essential tasks of the job for which you have applied?
 Yes
 No
If yes, please specify:
Do you take any medication that may affect your ability to do the job?
 Yes
 No
If yes, please specify:
Do you have any allergies?
 Yes
 No
If yes, please specify:
Are you a citizen of Australia?
 Yes
 No
If no, are you legally allowed to work in Australia?
 Yes
 No
Are there any languages (other than English) you can read, speak, or write fluently?
 Yes
 No
If yes, please specify:
EDUCATION
Secondary school(s) attended
Period of attendance
Level of attainment
FURTHER EDUCATION AND TRAINING (including short courses)
Proof of training, qualifications or membership of professional organisations you record below may be
requested. Please attach a separate sheet if there is insufficient room below.
Course:
Institution:
Period
attendance:
of
_____/_____/_____ to _____/_____/_____
Level of attainment:
Course:
Institution:
Period
attendance:
of
_____/_____/_____ to _____/_____/_____
Level of attainment:
EMPLOYMENT HISTORY
Please provide details of your current or most recent employment. Please attach a separate sheet if there is
insufficient room below.
Position:
Employer:
Period:
_____/_____/_____ to _____/_____/_____
Capacity:
 Full-time
 Permanent part-time
 Casual
 Volunteer
Duties:
Reason for
leaving:
Please provide details of your previous employment.
insufficient room below.
Please attach a separate sheet if there is
Position:
Employer:
Period:
_____/_____/_____ to _____/_____/_____
Capacity:
 Full-time
 Permanent part-time
 Casual
 Volunteer
Duties:
Reason for
leaving:
Please provide details of two (2) referees whom we may contact in regards to your
employment history. Please note a referee cannot be a family member or friend. Preferably,
your referees should be an individual who has been your work supervisor, or an individual you
have known professionally or through an organised activity for at least 12 months.
Name:
Relationship
Phone:
Email:
INVOLVEMENT
Are you prepared to provide clients with assistance in the following tasks? Where applicable,
please record any previous experience.
Toileting
 Yes
 No
Meal Assistance
 Yes
 No
Showering
 Yes
 No
Dressing
 Yes
 No
Cleaning
 Yes
 No
Manual Handling
 Yes
 No
Other
 Yes
 No
Are there any tasks which you cannot do due to health and/or fitness concerns (e.g. preexisting back injury, heart problems etc.)?
 Yes
 No
If yes, please specify:
AVAILABILITY
Days
Monday
Tuesday
Wednesday
Thursday
Please specify times available over
a 24 hour period
Please specify any time(s) you are
definitely not available
Friday
Saturday
Sunday
Are you available to work sleepover shifts?
 Yes
 No
Other availability details:
If appointed to the position, when could you commence? _____/_____/_____
ESSENTIAL QUALIFICATIONS/NOTICES
Queensland Driver License
Number: _________________
R, HR)
Type(s): ____________ (C,
 Automatic
 Manual
_____/_____/_____
Do you have your own vehicle to use for work?
 No
Blue Card
Number: _________________
_____/_____/_____
Expiry date:
 Yes
Expiry date:
If you do not currently hold a Blue Card, are you willing to obtain
one?
 Yes
Positive Notice Card (Yellow
Card)
 No
Number: _________________
_____/_____/_____
Expiry date:
If you do not currently hold a Yellow Card, are you willing to
obtain one?
 Yes
Current First Aid Certificate
(including CPR)
 No
Expiry date: _____/_____/_____
If you do not hold a current First Aid Certificate (including CPR),
are you willing to obtain one?

Yes
 No
DECLARATION
I,___________________________________________________________________________________,hereb
y:
(a) certify that the particulars contained in this employment application are correct, and
(b) give YellowBridge QLD Ltd permission to verify information contained in this application
(including, where applicable, that pertaining to my current and/or former employment
and education, and any previous WorkCover claims), and
(c) agree that, if employed by YellowBridge QLD Ltd, I will:
(i) work in accordance with the provisions of the employment contract and Award under
which I may be employed; and
(ii) adhere to the policies and procedures of YellowBridge QLD Ltd, and
(d) declare that I have not been involved in and/or convicted of acts of a criminal and/or
anti-social nature (including assault, abuse, drug abuse, dangerous driving and/or other
related offences), and
(e) acknowledge my full understanding and acceptance that my provision of any false
and/or misleading information in this application (whether intentional or otherwise) will be
deemed sufficient grounds for immediate termination of employment with YellowBridge
QLD Ltd.
_____/_____/_____
Date
Signature
OFFICE USE ONLY
Date received:
_____/_____/_____
Application
complete:
 Yes
 No