Application for Employment Form WA

My Supports Application for Employment Form

Western Australia Applicants
Part 1: Applicant Details
Name

First Name Last Name
Date of Birth
E-mail
Mobile Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Smoking Status

Smoker Non-Smoker
How did you hear about My Supports?

Website Social Media Local Print Ad Word of Mouth
Team Applying (Your Local Government Area)
Role Applying
I have a current Motor Vehicle License and Vehicle

Yes No
Do you have any special drivers licence conditions or medical conditions that may effect your driving?
Part 2: About Me
Tags

Tags help us best match our support workers with our clients based on cultural background, skills, hobbies and qualifications.
Please tick the boxes that are relevant to you

Aboriginal & Torres Strait Islander Advocacy Art and Crafts Certificate in Aged Care Certificate in Disability Education Behaviours Experience with Challenging Behaviours Cleaning Computers First Aid Certificate Gardening Handy Work Host Family Manual Handling Skills Music PEG Trained Photography Sports Therapist (Qualified) CALD Background (Culturally and Linguistically Diverse)
If you Ticked CALD, please let us know your Cultural Background
Availability
Please tick the days you are available to work. If you need to let us know about specific times etc. use the notes box below.

Monday AM Monday PM Tuesday AM Tuesday PM Wednesday AM Wednesday PM Thursday AM Thursday PM Friday AM Friday PM Saturday AM Saturday PM Sunday AM Sunday PM
Please let us know what days and times you would be available to work.
Notes
Qualifications and Work Experience in Disability
I have worked as a Disability Support Worker

Yes No
I have qualifications or certificates related to working with Disability

Yes No
If yes, please provide details
I have experience in Advocacy and representing the rights of people with a disability.

Yes No
If yes, please provide details.
Checks and Clearances

If you do not currently have the following checks and clearances you will need to obtain them if you are offered a position with My Supports.
National Police Clearance

Yes No
Working with Children Check

Yes No
First Aid Certificate

Yes No
Manual Handling Skills (this is not a requirement)

Yes No
Please Provide Two Referees
Referee 1 Name
Company Name
Contact Number
Contact Email
Referee 2 Name
Company Name
Contact Number
Contact Email
I authorise and consent to My Supports contacting my previous employers and referees at any stage of the recruitment process. I recognise that reference checks do not mean I am guaranteed a position with My Supports.

Yes No
Part 3: Values
I have lived experience of disability, as a family carer or friend or I am a person with a disability.

Yes No
If yes, please describe
What Values and skills could you bring to My Supports?
What do you feel is the most important role of a Support Worker or Coordinator?
Part 4: Legal Information
Offences, charges and related matters.
Have you ever been charged or convicted of any offence?

Yes No
If yes, please supply details
Have you received any charges or convictions related to driving offences?

Yes No
If yes, please supply details
Have you ever resigned or been dismissed from a position because of allegation of theft, dishonesty or unacceptable work practice?

Yes No
If yes, please supply details
Have you ever been the subject of a disciplinary proceedings by your employer or a governing regulatory authority e.g. Work Safe (or equivalent)

Yes No
If yes, please supply details
Medical Information

Section 79 of the Workers compensation and Injury Management Act sets out the following:
Willful and false representation: "where it is provided that the worker has, at the time of seeking or entering employment in respect of which he claims compensation for an injury, willfully and falsely represented himself as not having previously suffered from the injury an arbitrator may in the arbitators discretion refuse to award compensation which otherise would be payable"
Have you ever made a Workers Compensation Claim?

Yes No
If yes, please supply details
Have you ever injured yourself at work, or received, or are currently receiving payment in relation to any illness or injury suffered by you?

Yes No
If yes, please supply details
Are you currently receiving medical treatment for any condition, or taking medication which could affect your work in the position applied for?

Yes No
If yes, please supply details
Part 5: Attached Documents

For your application to be processed you must attach the following documentation;
Resume *
Current Drivers License or other valid ID
National Criminal History Check
Working with Children Check
Please note if your application is successful you will need to obtain the following certification:
- National Criminal History Check
- Working with Children Check
Part 6: Declaration
I certify that all the above information in this form is true, correct and complete.

Yes
Applicant Signature
Date Completed

Month Day Year
If your Application is successful you will be notified by phone and will be required to attend an interview.
Should be Empty:

My Supports Application for Employment Form

Part 1: Applicant Details

Part 2: About Me

Tags

Availability

Qualifications and Work Experience in Disability

Checks and Clearances

Please Provide Two Referees

Part 3: Values

Part 4: Legal Information

Offences, charges and related matters.

Medical Information

Part 5: Attached Documents

Part 6: Declaration