D&D Group

First Name *

Gender * Male Female

Date of Birth *

Home Address *

Post Code *

Home Phone *

Mobile *

Email *

Name *

Phone *

Address *

Relationship *

Which state are you applying for? * New South Wales Queensland

First Aid * Yes No

Expiry

Attachment *

Driver’s Licence * Yes No

Expiry

Type P1 P2 C LR MR HR HC MC

Transmission Auto Manual

Attachment *

Other

Description

Attachment

Other

Description

Attachment

Traffic Controller * Yes No

Motorways * Yes No

Suburban Streets * Yes No

Night Work * Yes No

Site Setup * Yes No

Major Roads * Yes No

Construction Site * Yes No

Truck Mounted Attenuator * Yes No

Draw TCPs * Yes No

Team Leader * Yes No

Team Leader/Ute Driver * Yes No

Total Months of Experience *

Company Name * Position Held * Start Date * Finish Date * Contact Name * Contact No * Daily Tasks * Reason for Leaving *

Company Name * Position Held * Start Date * Finish Date * Contact Name * Contact No * Daily Tasks * Reason for Leaving *

Are you physically fit to carry out Traffic Control duties * Yes No

Are you fit to handle equipment including sand bags, signage, hats, stop/slow bats * Yes No

Are you fit to work in extreme weather conditions including dusty, windy, wet, cold * Yes No

Are you fit to stand for long periods of time * Yes No

Are you fit to work on and / or near roads, motorways, freeways * Yes No

Are you fit to travel long distances * Yes No

Are you suffering from back or neck pain or stiffness * Yes No

Are you suffering from stiff / aching shoulder, elbow, wrist, hip, knee, ankle or feet * Yes No

Are you suffering from a stiff or sore back * Yes No

Are you suffering from any hearing impairment * Yes No

Are you suffering from any medical condition * Yes No

Have you had surgery, treatment or medication relating to the above information * Yes No

Are you currently restricted from performing any work related activity * Yes No

Provide details

Are you currently taking any drugs or medication * Yes No

Provide details

Provide details if yes to any of the above.

Have you made any previous Workers Compensation Claims? * Yes No

Claim 1

Date of Injury

Name of Employer

Address of Employer

Nature of Injury

How did Injury Occur

Name of Insurer

Duration of Absence of Work

Has Claim been resolved? Yes No

Was there an award made in your favour for permanent impairment in respect of the claim, if so, what loss or losses?

Will you provide a high level of customer service to clients and public * Yes No

Will you work as part of a team * Yes No

Will you undertake your duties in a safe and ethical manner * Yes No

Will you arrive for work on time with the correct PPE and tickets * Yes No

Will you attend inductions and training in your own time * Yes No

Will you comply with zero tolerance policy for illicit drugs and alcohol * Yes No

Are you available to work day shifts * Yes No

Are you available to work night shifts * Yes No

Are you available to work weekend shifts * Yes No

Are you available to work public holiday shifts * Yes No

Are you available to work overtime * Yes No

Are you available to work at sites overtime * Yes No

Are you available to accept phone calls at any given time * Yes No

Are you available to work on remote projects - Living Away From Home * Yes No

Please select your requested minimum Hours of Work per week * 10 15 20 25 30 35

Have you had any insurance cancelled or refused * Yes No

Have you had any special conditions imposed or renewal not offered * Yes No

Have you had any claims * Yes No

Have you had any fines * Yes No

Have you lost your licence * Yes No

Provide details if yes to any of the above

Will you participate in the pre-employment hearing test * Yes No

Will you participate in the pre-employment urine drug screen * Yes No

Will you participate in on the job urine drug screen * Yes No

Contact Name *

Position *

Contact No *

Contact Name *

Position *

Contact No *

Advertising * Yes No

Word of Mouth * Yes No

Website * Yes No

D&D Employee (enter details in comments below) * Yes No

Comment

Attachment

Attachment

* I certify that the answers, information and statements made in this application form are correct and to the best of my knowledge.

* I understand this information may be subject to verification and I authorize the company to approach any and all third parties identified by me and included in this application for this purpose. I hereby authorize all third parties specifically identified by me in this application to release to the company such information as it may reasonably require verifying the information that I have disclosed in this application.

* I understand that to supply information, which is false or misleading as part of this application is extremely serious. I understand that to be employed on the basis of falsified or misleading information would subsequently give the company grounds to immediately terminate my employment.

* I understand that I may be liable for all costs incurred by the company as a result of falsified information D&D Traffic Management reserves the right to reject an application based on evidence presented.