Application for employment

1. Personal Details

Prefix

Prefix other

Given Name(s)

Surname

Preferred Name

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Email

Mobile

Landline

4. Employment History

1. What is your current employment status?

Employed

Self Employed

Unemployed

2. Have you previously worked for Elderbloom?

Yes

No

(If yes please provide details on location, position and dates)

3. Have you previously applied for work with Elderbloom?

Yes

No

4. Have you any family members living or working at Elderbloom?

Yes

No

(If yes please provide details)

5. Please provide your employment history in the table below, starting with your current or most recent position

Start Date

End Date

Company Name

Position

Reason for Leaving

5. Education and Qualifications

1. Have you completed Year 10 or equivalent education?

Yes

No

(if no, what level did you achieve?

2. Please provide details on any other qualifications:

Qualification

Institution

Date of achievement

3. Other qualifications being pursued:

Qualification

Institution

Proposed date for Completion

4. Registration Details – for occupations requiring formal registration for employment:

Type of Registration (e.g. Nursing)

Expiry Date

6. Referees

Please provide details of two referees. Your nominated referees should be your supervisor in your current or most recent working environments and where possible, provide information relevant to the type of role for which you have applied.

By completing this section, you are giving permission for Elderbloom to contact your nominated referees to provide information relevant to your application.

1. Referees

Name

Position

Organisation

Working relationship to you

Telephone Contact

Email:

2. Referees

Name

Position

Organisation

Working relationship to you

Telephone Contact

Email:

7. National Criminal (Police Clearance) History Check

Employment in aged care requires a National Criminal History Check (Police Clearance) to be obtained as required under the Aged Care Act 1997.
If offered employment with Elderbloom this will be subject to you completing the required documentation to enable Elderbloom to process an electronic Police Clearance.
A criminal record does not necessarily disqualify an applicant. If rejection of your application is considered solely because of a criminal record, you will be given the opportunity to discuss the matter fully and confidentially with a senior member of staff before a decision is made.

1. Do you have any convictions for any offences from any court?

Yes

No

(if yes, please provide details)

2. Do you have any charges pending before any court?

Yes

No

(if yes, please provide details)

3. Are you prepared to complete the required National Criminal History Check prior to accepting and commencing employment with Elderbloom?

Yes

No

8. Mandatory Vaccination Check

Employment in aged care requires Mandatory Vaccination check to be obtained as required under the Aged Care Act 1997.

If offered employment with Elderbloom this will be subject to you providing an official vaccination record indicating you have been fully vaccinated for:

Current annual Influenza (Flu) Vaccination
COVID Vaccination

1. Have you received the current annual Influenza Vaccination?

Yes

No

(if yes, please provide copy of the vaccination certificate)

Max. file size: 256 MB.

2. Have you been fully vaccinated (2 x doses plus 1 x booster) for COVID ?

Yes

No

(if yes, please provide copy of the vaccination certificate)

Max. file size: 256 MB.

3. If you answered no to either/both of the above questions would you be agreeable to complete the required vaccination/s prior to accepting and commencing employment with Elderbloom?

Yes

No

9. Evidence of Work Rights Status

Please complete Section A or B

A. Australian Citizen (Including New Zealand)
Please provide the original of one of the following documents to be copied and sighted:

Passport

Birth Certificate - plus photo ID e.g. Driver’s licence

Citizenship Certificate - plus photo ID e.g. Driver’s licence

B. Non-Australian Citizens (excluding New Zealand)
Please complete the following: (As specified in passport or other identity document)

Family Name:

Given Name(s):

Other name(s) e.g. Maiden Name

Date of Birth:

Nationality:

Passport Number:

Visa Number:

Visa Expiry Date:

I authorise the department to release the details of my work rights status (that is, my entitlement to work legally in Australia) to Elderbloom Community Care Centres.

I understand that these details are held on departmental files and computer systems. I further understand Elderbloom Community Care Centres will use this information for the purpose of establishing my legal entitlement to work in Australia, and for no other purpose. I also understand that I allow release of my work rights for the duration of my employment with Elderbloom Community Care Centres.

I declare that the information I have provided is true and correct to the best of my knowledge and belief

Employee Signature:

Date

Employer Details:

Business Name:	T/As Elderbloom Community Care Centres
Business Street Address:	55 Belgrade Road Wanneroo WA 6065
Australian Business Number:	85 599875 887

Declaration

I declare that the statements I have made and the information I have given are true to the best of my knowledge and belief.
I have not withheld any relevant information required by this application, or made any false or misleading representations.
I acknowledge that if I have knowingly or wilfully given false or misleading information or have withheld any information, it could result in:

1. Rejection of my application;
2. Legal proceedings against me; or
3. Dismissal after appointment.

I understand that appointment to Elderbloom is conditional upon production of proof of identity, proof of residency status and a current satisfactory national police clearance.

Employee Signature:

Date

1. Personal Details

2. Position Details

3. Residency

4. Employment History

5. Education and Qualifications

6. Referees

7. National Criminal (Police Clearance) History Check

8. Mandatory Vaccination Check

9. Evidence of Work Rights Status

Please complete Section A or B

Employer Details:

Declaration

Enriching lives

At Elderbloom we aim to enrich the lives of our elderly residents by providing the highest level of care based on equity, independence, quality, empowerment and financial viability.

Administration

Resources

Care Locations