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Personal/Contact Details

By completing this Form, you are confirming your Registration of Interest for employment with Mass (Mass Resources), or one of its subsidiary companies. We require copies of all Identification, Licences, Tickets, Qualifications, Inductions, Police Clearances, Medicals, and documents proving your Rights to Work in Australia. Incomplete applications are not able to progress.

Name(Required)

First Last

Occupation

Address(Required)

Street Address Address Line 2 City State / Province / Region Postcode

Mobile(Required)

Phone

Email(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Drivers Licence No

Class

C

R

RE

LR

MR

HR

HC

MC

Own Transport?(Required)

Yes

No

If no, how do you get to work?(Required)

Are you of Aboriginal and/or Torres Strait Islander origin?(Required)

Yes

No

If you answered 'Yes' to the above, which describes you?(Required)

Aboriginal

Torres Strait Islander

Would you be happy to submit to the following, if required?

Pre-Employment Medical(Required)

Yes

No

Drug & Alcohol Screening(Required)

Yes

No

Traffic History Check(Required)

Yes

No

Criminal History Check(Required)

Yes

No

Have you ever been convicted of any criminal offences?(Required)

Yes

No

If yes, please specify:(Required)

Right to Work in Australia / Personal Identification

We have a legal responsibility to obtain evidence of your right to work in Australia. Please provide one of the following:

I am providing an Australian Citizen / Permanent Resident Certificate Number AND Photo Identification (e.g. driver's licence):(Required)

Yes

No

Australian Citizen / Permanent Resident Certificate Number, AND(Required)

Photo Identification (e.g. driver’s licence)(Required)

OR

I am providing an Australian or New Zealand Passport Number:(Required)

Yes

No

Australian or New Zealand passport Number(Required)

OR

I am providing a full Australian Birth Certificate AND Photo Identification (e.g. driver's licence):(Required)

Yes

No

Full Australian Birth Certificate AND(Required)

Photo Identification (e.g. driver’s licence)(Required)

ALTERNATIVELY, IF NONE OF THE ABOVE APPLY

I am providing an International Passport Number:(Required)

Yes

No

International Passport Number(Required)

How did you hear about Mass?

Please choose one or more options below:

Mass Website

Job Boards / Indeed / Seek

Walk-in

Internet (e.g. Google)

Facebook / LinkedIn

Instagram / Twitter

Referred by a Friend

Other: Please specify

Other: Please specify

What are your work location preferences ?

What are you work location preferences?(Required)

Local work only

FIFO work only

Local & FIFO Work

Are you available to work night shift?(Required)

Yes

No

What days you are available to work?(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Notice required in current position?

Do you wish to receive future communications about other employment opportunities?(Required)

Yes

No

Have you been in receipt of income support payments (such as JobSeeker Payment, Youth Allowance (Other), or Parenting Payment) over the last 3 months?(Required)

Yes

No

If Yes, please specify:(Required)

PPE & Uniform Sizes

Height

Shirts

Jackets

Pants

Gloves

Boots

Work History / References

Company Name(Required)

Site(Required)

Contact Name(Required)

Contact Title(Required)

Your position(Required)

Contact Number(Required)

End Date(Required)

DD slash MM slash YYYY

Start Date(Required)

DD slash MM slash YYYY

Summary of duties(Required)

Company Name

Site

Contact Name

Contact Title

Your position

Contact Number

Start Date

DD slash MM slash YYYY

End Date

DD slash MM slash YYYY

Summary of duties

Emergency Contact Details

Name(Required)

Relationship(Required)

Mobile(Required)

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Pre-Employment Medical Declaration

Have you ever had a work-related injury or illness?(Required)

Yes

No

Have you ever had a sporting injury?(Required)

Yes

No

Have you been hospitalised for any injury or had an operation?(Required)

Yes

No

Is there any reason why you cannot wear safety or protective equipment?(Required)

Yes

No

Do you have any injury or illness that would impact your ability to perform(Required)

Yes

No

Are you taking any medication?(Required)

Yes

No

Do you need to wear glasses for your normal work?(Required)

Yes

No

If Yes, do you have prescription safety glasses?

Yes

No

Are you currently being treated by any doctor?(Required)

Yes

No

Have you ever been refused life insurance, disability insurance, employment, or military service?(Required)

Yes

No

Have you ever tested positive in any workplace drug & alcohol test?(Required)

Yes

No

Is there a family history of any medical conditions?(Required)

Yes

No

For any past injury, work-related or personal (e.g. sporting) please provide details below

Details - 1.

Work-related?

Yes

No

Nature of injury

Date of injury

DD slash MM slash YYYY

Employer

Days off (in any)

Have you received a Final Medical Clearance / fully recovered from this injury?

Yes

No

Details - 2.

Work-related?

Yes

No

Nature of injury

Date of injury

DD slash MM slash YYYY

Employer

Days off (in any)

Have you received a Final Medical Clearance / fully recovered from this injury?

Yes

No

Details - 3.

Work-related?

Yes

No

Nature of injury

Date of injury

DD slash MM slash YYYY

Employer

Days off (in any)

Have you received a Final Medical Clearance / fully recovered from this injury?

Yes

No

Are you currently taking any prescribed / over the counter medications?

Details - 1.

Name of Medication

Treatment for

Dosage

Side effects (if any)

Details - 2.

Name of Medication

Treatment for

Dosage

Side effects (if any)

Details - 3.

Name of Medication

Treatment for

Dosage

Side effects (if any)

Employee Declaration

Before signing the declaration below, please read the following points and clarify anything that you are unsure of with a member of the Mass Team.

Consent(Required)

I agree to the privacy policy.

Acknowledge the following by signing below:
1. I confirm that all information I have provided in the Mass Candidate Registration Pack including all sections of the “Pre-employment Medical Declaration” is true, correct, and current.

2. I understand the collection of information about me is used to determine my suitability for employment with Mass or any third parties. I authorise Mass to use this information (which may include disclosing to third parties) to inform me of jobs, offer me jobs and refer to third parties who may form part of my employment process with Mass.

3. I declare that under Section 79 of the Western Australian Worker’s Compensation, and Injury Management Act 1981 I am required to disclose any prior illness or injury; failure to comply may result in loss of compensation entitlements in the event of illness or injury.

4. I agree to reimburse the FULL COST of any medical, drug & alcohol screening or booked VOC’s/training by way of invoice, unreasonably incurred by Mass for reasons that fall within my control.

Name(Required)

First Last

Date(Required)

DD slash MM slash YYYY

Employee Signature(Required)

Has there been a previous worker’s compensation claim?(Required)

Yes

No

Is OSH approval required?(Required)

Yes

No

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They power productivity and drive industry. We help power your workforce.

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Infrastructure

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Jobs

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List a Job

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Contact us

Phone 1800 964 566

Perth Office (08) 9381 4525
Darwin Office (08) 7902 9012

info@massresources.com.au

© 2022 Mass Resources.

Perth | Darwin | 1800 964 566 | info@massresources.com.au

Candidates
- Powering Careers
- Register with us
Companies
- Powering Productivity
- List a Job
Industries
About
- Leadership Team
News
Contact