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Workforce Testing Registration -Form Fill

Section One
Q1

Your Name *

First Name
Q2

Your Name *

Middle Name
Q3

Your Name *

Last Name
Q4

Date of Birth*

Day
Q5

Date of Birth*

Month
Q6

Date of Birth*

Year
Q7

Your Phone Number*

Phone Number
Q8

Address*

Street Address
Q9

Address*

Street Address Line 2
Q10

Address*

City
Q11

Address*

State / Province
Q12

Address*

Postal / Zip Code
Q13

Emergency contact*

First Name
Q14

Emergency contact*

Last Name
Q15

Emergency contact number*

Phone Number
Q16

Tickets and IDs - Please upload a copy of your tickets, White card, Drivers license.*
Q17

What role have you applied for? *
Q18

Do you have the following? *
Q19

Pre-Medical Part 1 - Do you have or have you suffered any other the following?*
Q20

Pre-Medical Part 1 - If you ticketed any of the boxes above, please provide further details below
Q21

HEALTH HISTORY*
Q22

HEALTH HISTORY - If you ticketed any of the boxes above, please provide further details below
Q23

Treatment or medical advice - Please Tick if you have any of the following?*
Q24

Treatment or medical advice - If you ticketed any of the boxes above, please provide further details below
Q25

PHYSICAL RESTRICTIONS - Do you have difficulties with any of the below?*
Q26

PHYSICAL RESTRICTIONS - If you ticket any of the boxes above please provide further details below?
Q27

APPLICANT’S DECLARATION
Q28

Declaration - Declaration *
Q29

Visa details - What type of Visa are you on?
Q30

Please attach a copy of your current passport
Q31

Superannuation Choice Form - Please select either 1. your choice of super fund. 2. You would like us to set you up with a super fund with the employer nominated fund CBUS. *
Q32

Candidate Declaration - Please sign to declare that the information you have given is true and correct, that you agree to employment with Erie Workforce on the terms and conditions set out in this employment contract.