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POSITIONPosition Applied For:Preferred location (if applicable):Date: / / PERSONAL DETAILSSurname:Given Names:Title:Address (include town & postcode):Daytime Phone No:Mobile Phone No:Email Address:Availability:(Please indicate the days and hours you are available to work, e.g.: 9:00am – 5:00pm)MondayTuesdayWednesdayThursdayFridayEDUCATION/TRAINING/QUALIFICATIONS – Please provide details: Certificates/Degrees HeldTraining PeriodName of InstitutionREFEREES – Please provide details of (minimum) two current referees:NamePosition Held & OrganisationContact Phone Number/sEMPLOYMENT HISTORY – Please list employment history for the past 5 years, with your most recent position first:EmployerFrom (month/year)To (month/year)PositionMain DutiesPlease select the response that is applicable.Do you know of any medical reason why you would not be able to perform this role?Yes/No.Are you willing for us to contact your previous employers as referees?Yes/No.Are you eligible to work in Australia?Yes/No.Are you willing to undergo a criminal records/working with children check/credit check? (as appropriate to the position you are applying for)Yes/No.Are you a current or recent patient or client of NCPHN services?Yes/No.How did you hear about this position? – please tick all that apply:NCPHN website?Seek?Career One?Koori Mail?Newspaper advert? If a newspaper, please specify which one:Other (please specify)?Please continue to page 3 to address the key selection criteria SELECTION CRITERIA – Please complete the table belowYou must address ALL the selection criteria as set out in the position description (please number each selection criteria response as set out in the position description)This is a compulsory requirement for your application to be consideredAttach a separate sheet if you need more spaceMANDATORY9525090805CAPABILITY FRAMEWORK00CAPABILITY FRAMEWORK63500-381000Personal Attributes63500444500Results63500bottom00People Management63500381000Relationships62865top00Business EnablersOther mandatory criteriaDESIRABLEDesirable criteriaDelete row if there are no desirable criteriaI hereby declare that all the information in this application is, to the best of my knowledge, true and correct. I understand that deliberately providing false or misleading information will disqualify me from consideration for the position, and may lead to my dismissal if already employed.APPLICANT’S SIGNATURE: _______________________________ DATE: __________ ................
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