RECRUITMENT AND SELECTION - City of Vincent

CITY OF VINCENT POLICY MANUALCHIEF EXECUTIVE OFFICER - HUMAN RESOURCESRECRUITMENT AND SELECTIONPOLICY NO: 5.2.1For any question above answered ‘yes’, complete the table below. If you need more space than is provided here,please write on the back of the page.Number Duration and Dates of Condition Current StatusApplicant DeclarationI hereby declare that:• I have read and understood the conditions on this form.• I have read the position description and selection criteria outlining the primary tasks of thisposition.• I understand that, if employed, the information I provide will be retained on my employee file andthat the employer reserves the right to access and use the information, in the event of an accident,injury, sickness or claim for workers’ compensation or for any other reasonable purposes, if sorequired by law.• I consent to the Local Government and its medical representatives obtaining or exchanging furthermedical information from my treating doctors or other health practitioners, if required for thepurposes of this assessment.• My answers relating to my medical and employment history are true and complete to the best ofmy knowledge. Furthermore there is nothing else regarding my health, well being or ability tocarry out the potential role which the Local Government or its medical advisers may need to knowto assess me for the position(s) I have applied.• I am fully aware that if I fail to disclose any relevant mater relating to my health, which renders meincapable of properly fulfilling the duties of the position, the employer may not employ me and ifalready employed by the employer, my employment may be summarily terminated.• I understand and agree that this report and any related health information provided may besupplied to the Local Government and its medical advisors.Name of applicant:Signature:Date:Assessment of Medical PractitionerApplicant name:Date of Birth:Position:Page 37 of 38