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Title

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Phone

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Address

Street Address

Address Line 2

City

State/ Province/ Region

ZIP/ Postal Code

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Email

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Date of Birth

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Next of Kin's Details

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Person One

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Name

First Name

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Person Two

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Name

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Qualifications

Position/s You are Applying For

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Registered Nurse

Enrolled Nurse

Personal Care Assistant

Disability Support Worker

Date Qualified

Speciality Area

Date Available to Begin Employment

Provide Days of the Week You are Available to Work

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Tuesday

Wednesday

Thursday

Friday

Saturday

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Nursing Board Registration Number 1 and Expiry Date

Nursing Board Registration Number 2 and Expiry Date

Working With Vulnerable Peoples Check Certification Number

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Cardiopulmonary Resuscitation (CPR) Competence

Course Completed

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Manual Handling Competence

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Drug Calculation Competency - Most Recent Date Undertaken

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Any Current or Past Medical Conditions to report?

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Any Current / Past Workers Compensation Claims?

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Proof Of Criminal Record Screening/ National Police Clearance - Date Issued

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Working with Children Clearance Number

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Superannuation

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Superannuation Usi No

Member Number

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Banking

Tax File Number

Institution or Bank Name

BSB Number

Bank Account Number

Tax Declaration Form

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Superannuation Nomination Form

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Pre-Employment Immunisation Assessment

Hepatitis A Vaccination Date

History

Result

Hepatitis B Vaccination Date

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Result

Varicella (Chicken Pox) Vaccination Date

History

Result

Measles Vaccination Date

History

Result

Mumps Vaccination Date

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Result

Rubella Vaccination Date

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Result

Influenza Vaccination Date

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Result

Diphtheria Vaccination Date

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Result

Pertussis Vaccination Date

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Result

Tetanus Vaccination Date

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Result

Poliomyelitis Vaccination Date

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Result

Tuberculosis Vaccination Date

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Result

Tuberculosis Previous Manteaux Test

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Tuberculosis Active Exposure

Chest X-Ray Date

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References

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Person One

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Name

Title

First Name

Last Name

Position/ Relationship

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Person Two

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Title

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Position/ Relationship

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Declaration

I Declare That The Above Information Is True And Correct, And I Acknowledge That The Deliberate Giving Of Information Will Result In This Application Not Being Processed

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