Candidate Profile Form – CBTB Coffee House

Name *

First

Last

Residential Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth *

What is your country of origin? *

Email *

Mobile Phone *

Are you currently working? *

Yes
No

Please provide more details *

How long have you not been working? *

What is your current hourly rate? *

Have you planned or are you planning to take holidays in the next (12) months? *

Yes
No

Please provide more details *

When will you be available to start? *

Do you have any career goals? *

Yes
No

Please provide more details *

Please detail any injury, illness, condition and/or disease you have suffered for which you: a) Lost time at work; or b) Received any form of treatment; or c) Received compensation for which is relevant to the essential requirements of any postion we feel would be best suited to you. *

Do you have an injury, illness, condition and/or disease that may be worsened by doing any work required by you for any position we feel would be best suited to you? *

Yes
No

Please provide more details *

Have you ever suffered an injury or illness that you believe may prevent you from being able to undertake any duties for any position we feel would be best suited to you? *

Yes
No

Please provide more details *

Have you ever worked in/with any of the following? Please select appropriate boxes *

If you have been unable to work due to problems working in the conditions outlined in the questions outlined above, please provide thorough details below.

Please provide more details *

Are you being treated by any medical practitioner for any injury, illness, condition or disease that may be a risk to food safety. *

Yes
No

Please provide more details *

Do you take any prescribed or non-prescription medications? *

Yes
No

Please provide more details *

Are you allergic or sensitive to anything that would prevent you from being able to safely undertake any duties of any position we feel would be best suited to you. *

Yes
No

Please provide more details *

Have you EVER had, or do you currently have any (GENERAL) injuries, illnesses, conditions or diseases? Please select appropriate boxes *

Please provide more details *

Have you EVER had, or do you currently have any (HEAD/NECK) injuries, illnesses, conditions or diseases? Please select appropriate boxes *

Please provide more details *

Have you EVER had, or do you currently have any (FOREARM/WRIST) injuries, illnesses, conditions or diseases? Please select appropriate boxes *

Please provide more details *

Have you EVER had, or do you currently have any (LEGS/KNEES) injuries, illnesses, conditions or diseases? Please select appropriate boxes *

Please provide more details *

Have you EVER had, or do you currently have any (BACK) injuries, illnesses, conditions or diseases? Please select appropriate boxes *

Please provide more details *

Have you EVER had, or do you currently have any (HAND/FINGERS) injuries, illnesses, conditions or diseases? Please select appropriate boxes *

Please provide more details *

Have you EVER had, or do you currently have any (ANKLES/FEET) injuries, illnesses, conditions or diseases? Please select appropriate boxes *

Please provide more details *

Have you EVER had, or do you currently have any (HIP/GROIN) injuries, illnesses, conditions or diseases? Please select appropriate boxes *

Please provide more details *

Do you have any convictions, finding of guilt and/or pending police charges against you? *

Yes
No

Please provide more details *

(Note: A National Police Check maybe a prerequisite for any position offered.)

What (3) words best describes your personality? *

Declaration of authenticity *

I accept the following statements as my own declaration of truth to the information submitted.

I hereby certify that the above information is correct and complete to the best of my knowledge and belief. I understand that, if I am employed, I will be liable to dismissal if any of the statements in my application are found to be deliberately misleading. I declare that, to the best of my knowledge, the information given is true and correct. I understand that inaccurate, misleading or untrue statements or knowingly withheld information may result in termination of employment with CBTB coffee house. I understand that this application does not constitute an offer of employment. I understand that, in some cases, police and credit checks will be required and I will be notified if this applies to this application. Special attention is drawn to the following: 1. You may be required to provide evidence of skills/qualifications and undergo a medical assessment prior to any offer of employment. If any false or misleading information has been provided by you in this application, you may be subject to instant dismissal. The collection, storage, access to and publishing of your personal information will be in accordance with the Australian Privacy Principles Act.