Employment Application Form
Position applied for:
Personal Details
First Name: Initials:
Surname: Name Known as:
Identity
number
Gender: Male Race: African
Female Coloured
Asian
White
Do you have a disability as defined by the Department of Labour? Y N
If yes, please specify:
Date of birth:
Are you a South African Citizen? Y N
If no, do you have a work permit to work in South Africa?
Y N
If yes, please provide a certified copy of your work permit attached to this application form.
Contact phon e numb ers: Residential Address: Postal Address:
Cell
Landline
Other
Page 1 of 6 pages
Job information
Part time: Full time: Y N
Y N
How did you hear about this position?
Qualifications
Highest qualification:
Institution:
Date qualified:
Other relevant qualifications:
Institution:
Date qualified:
Previous Employment
Employer: Job Title:
Start date: End date:
End salary and benefits:
Reason for leaving:
Present Employment
Employer: Job Title:
Start date:
End salary and benefits:
Reason for wanting to leave:
Page 2 of 6 pages
General
Have you previously:
Applied to work at a Life Healthcare hospital or business unit?
Y N
Worked at a Life Healthcare Hospital or business unit?
Y N
If yes, which hospital or business unit and what was your position title?
Do you have any relatives employed by Life Healthcare? Y N
If yes, please give details:
Do you have any physical health limitations that will prevent
Y N
you from performing the job that you are applying for?
If yes, please give details:
Where applicable, and in the execution of you r normal duties, you may be exposed to certain
health risks. The following are examples of such health risks:
Manual handling of objects or patients (i.e. muscular-skeletal problems, back-, neck- or
shoulder pain)
Latex (i.e. dermatitis, asthma)
Radiation (i.e. pre-malignant or malignant condition)
Chemicals (i.e. dermatitis, asthma, chronic bronchitis)
If you have any of the above or another condition that may be worsened and may have an
impact on your appointment, please disclose such information below:
Page 3 of 6 pages
Registration to work
Do you require a licence or registration to perform the work you are
applying for? Y N
If yes, please complete the following:
Registration type: Registration number:
Registration Body: Registration date:
Renewal date: Expiry date:
Country issued:
References
1. Company:
Position:
Contact Person name:
Position of contact person:
Contact phone number:
2. Company:
Position:
Contact Person name:
Position of contact person:
Contact phone number:
Page 4 of 6 pages
3. Company:
Position:
Contact Person name:
Position of contact person:
Contact phone number:
May Life Healthcare contact the references listed above? Y N
Consent & Declaration
It is in both your and the Company’s best interest to perform integrity assessments prior to
employment. An integrity assessment involves compiling a comprehensive background check
relevant to the job that will be performed, for example all employees working in the finance
sector must have their references and qualifications verified as well as a credit and criminal
record check. One or more of the following methods are used:
Reference check with referees as supplied
Qualification check
SANC check (if applicable)
Credit and/or criminal check
I hereby voluntarily provide consent for an integrity assessment to be carried out on me. I
accept that the integrity assessment is part of the pre-employment selection process and that
Life Healthcare is under no obligation to make use of my services. Please note that the
information gathered will be dealt with on a strictly confidential and discreet basis.
Is there any other information, which may have a bearing on your suitability for the position?
Y N
If yes, please detail (nature, date)
Date: _____________________ Place: _______________________
Signature: _______________________________________ ________
Page 5 of 6 pages
Declaration:
I hereby declare that all particulars and ans wers in this application form are true and no
material fact has been withheld. I agree that this application and declaration shall be the
basis of any contract between the Company and me, that the withholding of any material
information or failure to answer the questions correctly will constitute a breach of a condition
of my employment (if I am successful in my application) for which I may be dismissed.
Signature Date
Recruiting Line Manager Date
Page 6 of 6 pages
