E4 Allied Health - Locum Registration Form

Welcome to E4 Allied Health. Thank you for taking the time to learn more about what we do and have us look for work for you on your behalf.

Below is our Expression of Interest form - if you are interested, please take the 4 minutes to fill it out. Once I have received it, I will get in touch with you to learn a little more about you and register you for work with us ongoing.

PERSONAL DETAILS

Title

Surname *

First name *

Middle name(s)

Address *

Suburb *

Postcode *

Email *

Tel mobile *

Tel home

Date of birth

ELIGIBILITY FOR EMPLOYMENT

Do you hold an Australian passport? *

YesNo

Please specify which visa you have

Visa Expiry

Date of entry to AUS / NZ

AHPRA Registration

Do you have current AHPRA Registration *

YesNo

AHPRA Registration Number *

EMPLOYMENT REQUIREMENTS

Profession *

Looking for locum, perm or both? *

Desired Locations

Max. time you are willing to travel to employment

If travel and accommodation are covered, are you willing to travel to rural locations for work?

Part-time or full-time? If part-time, how many hours a week? Are you open to working weekdays, weekends or both?

Date available for work

Do you have a valid drivers licence? *

YesNo

Do you have access to a car for work purposes? *

YesNo

Are you willing to drive to a site if it is required? *

YesNo

What type of role are you ideally looking for? Aged-care, hospital, community etc.

Is there any type of role are you not willing to be considered for?

DISABILITIES

Do you have a disability under the terms of the Disabilities Discrimination Act? *

YesNo

Please describeIf you have any disabilities, please let us know if we need to make adjustments when assisting you with your search for work.

RECENT RESUME

Please attach a copy of a recent resume if you have not already sent us one.

Resume

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REFERRAL

If someone referred you, please write their name here.

DECLARATION

I accept the terms and conditions of E4 Recruitment (which I have received). *

I declare that the details given by me on this application form are correct to the best of my knowledge and belief. I understand that if I have given any information which is false, or I withhold any relevant information, this may lead to my application being rejected or if already appointed, to my dismissal. *

I have engaged E4 Recruitment to act on my behalf to source employment and authorise my resume and details to be presented to their clients.
*

Signature

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Date

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