Total Care Logistics - Rate Request

Position Applied for	:	*
Last Name	:	*
First Name	:	*
Address	:	*
Postcode	:
Email Address	:	*
Telephone	:
Mobile	:
Date of Birth	:	*

Drivers licence no.	:
State	:
Class	:
Exp. Date	:

In case of emergency, Please notify	:	*
Relationship	:	*
Email Address	:
Telephone	:
Mobile	:
Address	:
Postcode	:

PHYSICAL AND HEALTH HISTORY
Please specify any pre existing medical conditions which may affect the applied for position?


Do you suffer from any back, neck, shoulder or knee complaints? Yes No
If yes please give detail :


Are you required to take medication that may :
Affect your work Performance? Yes No
Affect yourattendance at work? Yes No

How much time have you lost from work in the past 3 years for illness?


Would you be willing to take a medical examination? Yes No
Would you be willing to take an alcohol and drug test? Yes No

DETAILS OF PREVIOUS EMPLOYERS
Date	:
Company	:
Position	:
Duties	:
Reason for leaving	:

Date	:
Company	:
Position	:
Duties	:
Reason for leaving	:

LIST TWO PROFESSIONAL REFEREES
Name	:
Company	:
Position	:
Telephone	:
Address	:
Postcode	:

Name	:
Company	:
Position	:
Telephone	:
Address	:
Postcode	:

Confirmation Code	:

		In submitting this application for employment, I acknowledge that any misrepresentaion of facts is sufficient for dismissal


		*Fields with ( ) are required**

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