PEP Registration & Health & Fitness Form

Date

DayMonthYear
Consultant
Full Name*

First NameLast Name
Gender

MaleFemaleNot Specified
Birth Date*

DayMonthYear
Postal Address*
Street Address
Town
State
Postcode
Country
Are you registered with a Government job service provider?*

NoAPM EmploymentAtwork AustraliaCampbell Page EmploymentCVGT SkillsESG / MatchworksEssential EmploymentGlobal SkillsMax EmploymentMBC EmploymentMission / KonektNova EmploymentSalvation Army / Employment PlusSarina RussoSureway EmploymentThe Personnel GroupTursaWISE EmploymentWorkskil AustraliaWorkskills - The Disability TrustOther
Contact Type
Contact
Mobile Phone Number*
E-mail Address
Home Phone Number
Emergency contact

Emergency Contact Person*

	Relationship	Surname	First Name	Mobile Phone Number	Other Phone Number
Emergency Contact Person Details

What Workcover Certificates/Licences do you have?

	WC - White Card	LF - Forklift	LE Excavator	MR - Medium Rigid	HR - Heavy Rigid	First Aid	EWP Working at Heights	Confined Space
I hold the following;

Other Workcover Certificates;

RSARCGDogmanTraffic ControlRTA BLUE/GREY CARDRTA RED CARDRTA ORANGE CARDRTA YELLOW CARDLB BackhoeLL Fronte end loaderLO Order picking LFLS Skid steer/BobcatAsbestosChemical CertificateSECURITYOther
Vehicle Licence Class

C - CarR - RiderLR - Light RigidMR - Medium RigidHR - Heavy RigidHC - CombinationMC - Multi ComboN/A
What sort of work are you after?
e.g. Labour, admin, warehouse etc.
What industries do you have experience in?
e.g. Construction, warehouse, admin, retail, hospitality etc.
Have you completed any trade qualifications?
e.g. Boilermaker, plumber, electrician etc.
Are you after full time hours or part time hours?

Full timePart time
How did you hear about us?*

WebsiteFacebookGoogleRadioWord of mouthYellow PagesJobsearchSignageOther
To find out about current jobs please like our Facebook page.
Upload Resume

Browse Files

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Comments, additional experiences and skills
Is there a specific job that we have advertised that you are interested in?
Health and Fitness Statement

The information obtained in this questionnaire will be treated in strict confidence and will only be used in conjunction with the requirements of a client assignment.
Medical information policy of Flexiforce Australia Pty Ltd (ABN 86 082 237 821) and Flexiforce Southern Highlands Pty Ltd (ABN 73 104 222 755) jointly to be known as the Employer or Flexiforce.

Flexiforce is committed to establishing and maintaining a safe and fair work environment for all prospective and current employees. This commitment is based on the principles of concern for the individual, selecting the best person for the job and minimising business risk.

Collecting medical information about current or potential employees has three purposes:

1.    To assess an applicant’s current ability to perform the inherent requirements of a job.

2.    To be alert to the possible dangers or risks to an individual’s health arising from the performance of particular work.

3.    To minimise business risk by ensuring the health, safety and welfare of all employees at the commencement of employment and during the course of employment.

This policy applies to the recruitment and employment of all employees.
You are required to disclose to Flexiforce any or all existing or pre-existing injuries, illnesses or diseases suffered by you which could prevent you from performing the duties associated with the employment for which you are applying with Flexiforce.

As per relevant legislation, if you fail to disclose this information or if you knowingly provide false or misleading information in relation to any pre-existing injury/condition you and your dependents may not be entitled to any form of workers compensation or to seek damages for any event that aggravates the pre-existing injury or medical condition and this may also constitute grounds for disciplinary action or dismissal.
Have you had Covid-19 Vaccincations?*

First Dose receivedFully vaccinatedNot vaccinatedOther

Have you ever had, or are you suffering from any of the following?*

	No	Yes
Heart trouble / Angina
High blood pressure
Chest Pain
Arthritis / Rheumatism
Back, neck or spinal trouble
Joint aches and pains
Sprains or strains
Chronic bronchitis / Asthma / Chest trouble
Persistent cough
Tuberculosis (TB)
Hay fever or allergies
Hepatitis, Yellow Jaundice
Diabetes
Dizzy spells / Giddiness / Fits / Fainting
Ear or hearing trouble
Eye trouble
Nail infection
Rupture or hernia
Skin rashes

If you answered yes to any of the above, please give further details below.
Have you ever been on Workers Compensation?*

No, I have never been on Workers Comp.Yes, I have been on Workers Comp previously.
If Yes, I have been on Workers Comp previously please provide details of injury.*
Have you had any motor vehicle or sports injuries?*

NoYes
If you answered yes, please give further details below.*
Have you had any surgical procedures (including during childhood)?*

NoYes
If you answered yes, please give further details below.*
Have you had any head injuries?*

NoYes
If you answered yes, please give further details below.*
Have you ever had any fractures or broken bones?*

NoYes
If you answered yes, please give further details below.*
I declare that the answers and information given are true and correct to the best of my knowledge.
Should be Empty:

Health and Fitness Statement