Employment Application Form

This form may be downloaded in PDF format or completed here as an online form.

Position Applied For:	(required)
ACT Registration Number:
Aged Care Certificate Number:
Previous Employment Details:	Please include dates and employer details:
Have you ever had your Nurses Registration cancelled or refused renewal (in any state or territory)? Yes No	If yes, please provide details:
Have you ever had a claim for Workers Compensation? Yes No	If yes, please provide details:

Do you have any physical illness that may
affect your employment?

Yes No

Have you ever suffered (or are suffering) from any mental disorders or breakdowns?
Yes No

Do you have an alcohol or drug related issue that may have an impact on your work performance?

Yes No

Are you up to date with current injections? Yes No	If yes, please give details:
Do you have a current First Aid Certificate? Yes No	If yes, please give details – Certificate Number, Organisation and Expiry Date
When was your last CPR Training undertaken? Yes No	If yes, please give details – date and provider:
When was your last Manual Handling Training undertaken?	Please give details – date and provider:
Have you undertaken recent training to improve or maintain your clinical skills? Yes No	If yes, please give details:
Would you like to undertake additional training to assist you in the field? Yes No	If yes, please give details:

Are you currently employed with another
nursing agency, hospital or medical
facility within the ACT?

Yes No

Preference for Employment

Hospitals

Nursing Homes

Home Care

Preference for Shifts

Morning

Evening

Night Shift

Please provide names and contact details for three Referees.

Please note: Referees are not to be family members and should be people who have worked with you previously.

Tax File Number:
Bank Name:
Branch:
BSB Number:
Account Number:
Name on Account:
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Please bring the following to your interview:

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