OPERATORS/ DRIVERS APPLICATION

FOR EMPLOYMENT
Company Name: Address: 373 Fry Street,
Grafton NSW 2460
Ph 0266049111

Read It is our policy to consider all qualified applicants for a position without regard to race, colour, religion, sex, national origin, age, marital status, or non-job related disability. In
This the event of employment, I understand that false or misleading information given in this form, interviews, medical or other employment processes may result in dismissal.
First I have read and understood the above statement: Date:
™
General
Full Name: Date of Application:

Current Address: Postcode: State:

Previous Address (if not at current address more than 12 months):

Current Phone Contact/s: Date of Birth:

Other Forms Of Contact (Fax / E-Mail):

Next of Kin (person to notify in emergencies): Relationship:

Next of Kin Address:

Next of Kin Phone Contact/s:

Employment History
List past 5 employers in order of last employer (1):
Employer Name Location Phone No Position held Period of Reason for leaving
(if known) (eg: driver) Employment
1

Accidents
List any Vehicle accidents in the last 5 years: (if none, write "None")
Date Nature of Accident Approx $ At Fault? Serious
(approx) (eg: single vehicle, head on, rear-ender) Damage (Y / N) Injuries /
(your vehicle) fatality (Y / N)

Issue: 2 ©National Transport Insurance LTD 2002 Page 1 of 5

Experience & Qualifications

List current licenses or authorisations (eg: drivers licence, DG authorisations, forklift / plant tickets, TFMS certification)
Type / classes Licence/Auth No State of Issue Expiry Date Years Held

Have you had your driver's licence cancelled or suspended? No Yes ™I f Yes provide details:

Are you a member of the Transport Workers Union? No Yes ™I f Yes provide details

Have you ever been convicted of a criminal offence? No Yes ™ If Yes provide details:

Provide details of demerit points lost (or pending to be lost) for previous 3 years:
Offence Points When Comments
Lost (approx)

Do you have authority to work in Australia? Yes / No

Either 1/ Provide this company a photocopy of you current drivers licence or 2/ allow the company to sight and record
licence details.

Please Tick: Allowed photocopy or Produced licence to allow recording of details.

Are you prepared to sign a letter of authorisation for this company to obtain details of your driving history from the relevant

road authority? No Yes

Issue: 2 ©National Transport Insurance LTD 2002 Page 2 of 5

Driving Experience

List your driving/work experience starting with most recent and working back:
Vehicle Type Type of Work Number of Years When Experience Whilst Employed by:
(eg: Rigid, Semi, B- (eg: tipper, fridge, Experience Gained (eg: XYZ TPT)
Double, Road Train) general) (eg: 2 years) (eg: 1997-1999)

Other Experience (if applicable):

What type of driving work are you seeking with our company?

Rigid Local: Yes / No

Articulated Semi Local: Yes / No
Long Distance Interstate Articulated Semi Yes / No

Any other Comments with type of work:

Note:

As part of your employment conditions, the company requires you to provide a licence print out of license every
12 months. The company will pay the cost of this requirement.

Superannuation

Are you a member of a Superannuation Fund? No Yes ™

If Yes provide details

Superannuation Fund:
Member Number:

Issue: 2 ©National Transport Insurance LTD 2002 Page 3 of 5

Education

List highest standard achieved at school (include where and when):

List any other courses or post school education or training that may help you in your work with this company:
What When What When

WorkCover

Are you currently receiving any form of worker's compensation? No Yes ™ If Yes provide details:

Do you have any claims pending or intend to lodge claims against former employers? No Yes ™ If Yes provide
details:

Do you have any physical, mental or learning disability or condition, which the Company may need to accommodate if

employed as a driver? (refer Job description for employment specifications, ask if not provided) No Yes ™ If Yes provide details:

Are you prepared to sign a letter of authorisation for this Company to obtain details of you compensation history from the

relevant Workcover authority? No Yes

Health

The Company reserves the right to require you to undergo both a pre-employment and if successful on-going medical
examinations by a company appointed doctor. The purpose of the medical is to protect public safety and as such the
NRTC "Medical Examinations of Commercial Vehicle Drivers" standard is used.

Do you agree to undergo medical examinations by the Company appointed doctor? No Yes

To aid in this process you are required to complete the "self report", attached to this employment form, which will be on-
forwarded to the Company doctor to aid in the medical examination process.

Additional Comments (if any):

Issue: 2 ©National Transport Insurance LTD 2002 Page 4 of 5

 TO BE READ AND SIGNED BY APPLICANT

This certifies that I completed this application and that all entries on it and information in it are true and complete to the
best of my knowledge.

I authorise you to make such investigations and inquiries on my personal, employment, medical history and other related
matters as may be necessary in arriving at an employment decision. I hearby release employers, health care providers,
government authorities and other persons from all liability in responding to inquiries and releasing information in
conjunction to my application.

In the event of employment, I understand that false or misleading information given in my application, interview, medical
or any other employment process may result in termination of employment. I also understand that I am required to abide
by all policy, procedures and rules of the company.

I understand that if I am successful in gaining a position with the company, that I will be on a probationary period of 90 day
from commencement of employment during which time my performance will be monitored.

Name of Applicant Name of Witness:

Signature of Applicant: Signature of Witness:

Date: Date:

Ð TO BE COMPETED BY Company Staff. Ð

Application meets company criteria? Yes No

Completed Comments / Records on File Not Acceptable Above
(Y / N) Acceptable Average
1 Application Form
2 Required License/s
- License Printout
3 Relevant Experience
4 Interview
5 Past Employment
- References Checked
6 Accident History
7 Criminal Convictions
8 Knowledge Quiz
9 Road Test
1 Driver Profile / Analysis
0
1 Medical Assessment
1
1 Workcover Claims
2
1
3
1
4

Employment Detail

Position: Approved By:

Start Date: Offer Letter Sent (date):

Induction Date: Inducted By:

Probation Review By: Date: Result:

Termination Detail

Date Terminated: Dismissed Quit other

Why:
Issue: 2 ©National Transport Insurance LTD 2002 Page 5 of 5
 MEDICAL SELF REPORT
(To be Completed by the Driver)

Please answer the questions by ticking the correct box. If you are not sure, circle and discuss with the doctor during the examination.

No Yes No Yes
1 Are you being treated by a doctor for any illness or 7 Have you ever had any other serious injury,
injury? illness, operation, or been in hospital for any
reason?
2 Are you receiving any medical treatment or taking 8 Have you ever:
any medication? 8.1 attempted to cut down on your drinking?

3* Have you ever had an accident as a result of 8.2 been annoyed with other people criticising
blacking out or falling asleep? your drinking?
4* In the past year, have you ever had to pull off the 8.3 felt guilty about your drinking?
road because you became sleepy?
If YES: How often? _______________ 8.

5 Have you ever contemplated or attempted suicide? 9 Do you use illicit drugs?
6 Have you ever had, or been told by a doctor that 10 Do you use any drugs or medications not
you had any of the following? prescribed for you by a doctor?
6.1 High blood pressure Applicant Declaration:
6.2 Heart disease
6.3 Chest pain, Angina I, _________________________________________
(Print Name)
6.4 Any condition requiring heart surgery
- certify that to the best of my knowledge the
6.5 Palpitations / irregular heartbeat
above information supplied by me is true and
6.6 Abnormal shortness of breath correct; and
6.7 Head Injury, Spinal injury - consent to the Doctor releasing medical
information to the perspective employer /
6.8 Seizures, Fits, Convulsions, Epilepsy employer in direct relation to my medical
6.9 Blackouts, Fainting eligibility for a commercial vehicle driving
position.
6.10 Stroke
6.11 Dizziness, Vertigo
Signature: _______________________
6.12 Double vision, Difficulty seeing
6.13 Colour blindness
Date: ________
6.14 Psychiatric illness, Nervous disorder
6.15 Kidney disease _________________________________________________
6.16 Diabetes Doctor Comments: (append pages if necessary)
_______________________________________________________
6.17 Sleep disorder, Sleep Apnoea,
_______________________________________________________
Narcolepsy
_______________________________________________________
6.18 Alcohol abuse _______________________________________________________
_______________________________________________________
6.19 Bleeding bowel or black motions
_____

Issue: 2 Source: Medical Examination of Commercial Vehicle Drivers (ISBN 0 64221209 0) Page 6 of 5