STA Registration Form

Safe Tasks (Aust) Pty Ltd Registration Form

QRS Group
Personal Details
Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Country of Birth*
Address*

Street Address

Street Address Line 2

CityState

Post Code Country
Postal Address If different to Above

Street Address

Street Address Line 2

CityState

Post CodeCountry
E-mail*
Phone Number*
Gender

MaleFemaleOther
Are you Aboriginal or Torres Strait Islander

AboriginalTorres Strait IslanderNeither of These
Are you currently registered with a Job Network Agency?*
If yes, please advise name of agency
If yes, please advise Jobseeker ID

Emergency Contact/Next of Kin
Emergency Contact*

First NameLast Name
Phone Number*
Relationship to you*
Address of Emergency Contact*

Street Address

Street Address Line 2

CityState

Post CodeCountry
Work Deatils
How much notice do you require for work*
Work Entitlements
Are you an Australian Citizen?*

YesNo (if no, please provide passsport details)
Passport Number
Country of issue (of passport)
Expiry Date (of passport)
Visa Type and Number
Do you consent to QRS Group checking your work entitlements with the Department of Immigration and Citizenship?*
Are you prepared to travel to and from work locations if required?*

Please upload your Resume

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Please upload your drivers license*

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Please upload a head and shoulder photo of yourself*

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Photo requirements ▪ Head and shoulder shot ▪ One person per picture ▪ No hats/hard hats etc ▪ No safety glasses or sunnies ▪ Can smile Cancelof
Confined Space Certificate

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Safe Working at Heights Certificate

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General Construction Induction Card (WhiteCard)

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Any other relevant Certificates

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Any other relevant Certificates

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Please upload your Resume

Upload a File

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Please upload your drivers license*

Upload a File

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Upload any other tickets and licenses

Upload a File

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Upload a File

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Upload a File

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Upload a File

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Resume Declaration
USI Number *
UNIQUE STUDENT IDENTIFIER (USI)

For more details regarding, HOW to obtain the USI personal number please visit the USI website: www.usi.gov.au and follow the step by step instruction on how to set up a USI number prior to any training & assessment

	Yes	No
Lung or breathing problems e.g. bronchitis, asthmas
High Blood Pressure
Epilepsy/Seizure
Broken Bones
Back/Neck Problems
Muscular or joint pain
Hernia
Heart/Chest pain
Arthritis
Sporting/Motor vehicle injuries
Faints, fits/convulsions
Frequent headaches
Eye or vision, Ear or hearing problems
Stroke
Cancer
Bleeding problems (abnormal)
Have you ever had to claim Workers Compensation?
Do you have a current Workers Compensation claim?
Have you ever had an accident/injury that has/could affect your employment
Have you ever had an industrial/work related accident?
Have you had time off in the last year due to any illness/injury?
Have you had any surgical operation in the last year?
Do you wear glasses or contact lenses?
Is there any reason you cannot wear personal protective equipment?
Have you suffered from RSI or Overuse Syndromes?
Have you worked in dusty or noisy conditions?
Have you ever worked with asbestos or chemicals
Have you experienced difficulty working in confined spaces
Do you suffer from Hayfever

	Yes	No
Running up to 100 metres
Walking on rough ground
Kneeling
Standing for 2 hours
Sitting for 2 hours
Turning your head rapidly
Concentrating on a task
Hearing a normal conversation
Climbing a ladder or stairs
Using hand tools
Lifting or bending
Gripping firmly with both hands
Reading ordinary print
Repetitive movement of hands/arms
Crouching
Understanding English

Safe Tasks (Aust) Pty Ltd Registration Form