POSITION APPLIED FOR:

Primary Skill/Attribute:

How did you hear about KI?

Select Advertisement Event Website Word of mouth Referral Other

Surname

First Name

Middle Names 

Residential Address

State

Select WA ACT NSW NT QLD SA VIC

Postcode

Postal Address

State

Select WA ACT NSW NT QLD SA VIC

Postcode

Home Telephone

Mobile Telephone

Date of Birth

Sex

Select Male Female

Email Address

Martial Status

Select Single Married De-Facto

Are you of Aboriginal or Torres Strait Islander descent ?

Select Yes No

Emergency Contact - Name

Relationship

Contact Address

State

Select WA ACT NSW NT QLD SA VIC

Postcode

Contact Telephone

Mobile Telephone

Drivers Licence No:

State

Select WA ACT NSW NT QLD SA VIC

Classes Held

Expiry Date(mm/yy)

Do you have any criminal convictions?

Select Yes No

If Yes please give details

Have you previously obtained a Police background check?

Select Yes No

Would you be willing to authorise a police background check?

Qualifications Achieved

Institution

Year Completed

INDUSTRIAL QUALIFICATIONS

Please list any training or certifications that you have:

Qualification

Cert Number

Year Completed

Expiry Date
(If applicable) 

Example: Forklift Ticket

77628A2

2003

12/06

TRADE QUALIFICATIONS

Please list your trade qualifications and the year they were achived:

Qualification:

Year Completed:

Employer:

Qualification:

Year Completed:

Employer:

Qualification:

Year Completed:

Employer:

Qualification:

Year Completed:

Employer:

SITE INDUCTIONS

Please list the company and sites to which you have been inducted.

Company Inductions

Site Location

Expiry Date
(If applicable) 

MEDICAL ASSESMENT QUESTIONNARE

Name:

Date:

Medical History
If you suffer from, or have experienced any of the following conditions please indicate Yes or No

High Blood Pressure

Select Yes No

Fainting or Light-Headedness

Select Yes No

Heart Trouble

Select Yes No

Loss of Balance

Select Yes No

Palpitations

Select Yes No

Nausea or gastric upset following exposure to fumes

Select Yes No

Stroke

Select Yes No

Stiffness or aching in neck, shoulder, elbow, or waist

Select Yes No

High Colesterol

Select Yes No

Stifness or aching in knees, or ankles

Select Yes No

Tennis Elbow, Overuse or Repetitive Strain Injury

Select Yes No

Weakness in arms or legs

Select Yes No

Asthma or Bronchitis

Select Yes No

Unexplained loss of weight

Select Yes No

Fits, Seizures, Epilepsy

Select Yes No

Sore eyes or skin rashes due to oil, chemicals

Select Yes No

Hay Fever

Select Yes No

Sore eyes or skin rashes due to animals, or plants

Select Yes No

Allergies

Select Yes No

Any joint problem or injury

Select Yes No

Eczema, Dermatitis

Select Yes No

Lung Problems

Select Yes No

Arthritis, Rheumatism

Select Yes No

Tuberculosis

Select Yes No

Whiplash/Neck Injury

Select Yes No

Frequent Cough

Select Yes No

Sight Defect

Select Yes No

Wheezing or whistling in you chest

Select Yes No

Fracture or Dislocation

Select Yes No

Breathless due to specific dust, fumes or gases

Select Yes No

Back Strain Injury

Select Yes No

Bleeding from bladder or bowel

Select Yes No

Diabetes

Select Yes No

Fainting or sickness due to high temperatures

Select Yes No

Mental or Nervous Disorder

Select Yes No

Cancer or Tumor

Select Yes No

If you have answered Yes, Please Give Details:

Physical Abilites
If you have any difficulty with the following activities please indicate Yes or No

Standing for 2 hours

Select Yes No

Gripping firmly with both hands

Select Yes No

Turning your head rapidly

Select Yes No

Understanding English

Select Yes No

Lifting 20kg

Select Yes No

Bending repeatedly

Select Yes No

Reading ordinary news print

Select Yes No

Hearing a normal conversation

Select Yes No

Concentrating for long periods

Select Yes No

Kneeling

Select Yes No

Running 100 Meters

Select Yes No

Sitting for 2 hours

Select Yes No

Climbing a ladder

Select Yes No

Crouching

Select Yes No

Climbing over rough ground

Select Yes No

Repetitive movements of arms or hands

Select Yes No

Using hand tools

Select Yes No

Working at height

Select Yes No

IMPORTANT – Section 79 of the Workers’ Compensation and Rehabilitation Act 1981
“Where it is proved that the worker has, at the time of seeking or entering employment in respect of which he/she claims compensation for a disability, willfully and falsely represented themselves as not having previously suffered from disability, a dispute resolution body may in its discretion refuse to award compensation which otherwise would be payable”.

Please specify any pre-existing medical conditions or injuries which may affect work for which you have applied.

Do you suffer, or have you ever suffered any ongoing back, or joint complaints?

Select Yes No

If Yes, give details below

Are you required to take medication which may affect your work performance / attendance at work?

Select Yes No

If Yes, give details below

Is there any reason why you cannot wear safety, and or protective equipment?
(Safety boots, gloves, glasses, hard hat, etc)

Select Yes No

If Yes, give details below

Have you lost time from work in the past three years due to illness?

Select Yes No

If Yes, give details below

Would you be willing to take a medical examination?

Select Yes No

Would you be willing to take an alcohol and drug test?

Select Yes No

Workers Compensation

Have you ever lodged a workers compensation claim?

Select Yes No

If Yes, give details below

STATEMENT

Thank you completing the Kimberley Industries on-line application for employment. Please take a moment to read the following. Kimberley Industries will house information you have supplied for the purpose of seeking employment, Information collected is used internally and may be disclosed to the following if necessary:
1. Clients or Potential Clients of Kimberley Industries for determining job suitability
2. Government Bodies such as the Australian Taxation Office or Superannuation funds
By selecting yes from the drop down menu indicates you accept the terms and conditions above and agree to the privacy policy. The privacy policy and further terms can be found here.
If no is selected Kimberley Industries may not be able to process your application.

Select Yes No

SUBMIT DESTINATION

Select the destination to deliver this application to

Select Rockingham Broome Kununurra Darwin