Instructions to Candidates:

This online form is to be filled out only by the candidate who is applying for the position.

The personal medical information you supply within this document may be provided to your prospective employer. We appreciate your co-operation in providing this information as accurately as possible.

Although some of the information asked for in this assessment may not seem relevant, the questions have been carefully chosen to enable the doctor to conduct a thorough assessment of your health and wellbeing in order to ensure that your job placement and subsequent duties will not expose yourself or others to an undue risk of illness or injury.

SECTION A – CANDIDATE DETAILS

* Company Name:
* Contact at Company:
* Position Applied for:
 
Mr
Mrs
Ms
Miss
Master
other
* Last Name:
* First Name:
Middle Name:
Preferred Name:
* Date of Birth:
Sex:
Male
Female
Nationality:
* Street address:
* Suburb:
* Postcode:
Postal address:
* Mobile Number:
* Ok to receive SMS notifications
Yes
No
* Email:
Name of Your Family Doctor:
Address of Family Doctor:
Contact Number of Family Doctor:
40876177572D0814DA333CCC88C127E5