PERSONAL DETAILS
PART A: PERSONAL DETAILS
SURNAME………………………………. PREVIOUS NAME……………………………….
GIVEN NAMES…………………………………………………………………………………..
DATE OF BIRTH ………………………. COUNTRY OF BIRTH…………………………..
ADDRESS………………………………………………………………..................................
…………………………………………………………………………POSTCODE…………...
TELEPHONE MOBILE EMAIL
…………………………. ………………………… ……………………….
EMAIL
PART B: EMERGENCY CONTACT
……………………………………………………………
RELATIONSHIP (MOTHER/FATHER/PARTNER ETC)……………………………………
SURNAME………………………………. GIVEN NAMES………………………………….
ADDRESS………………………………………………………………..................................
…………………………………………………………………………POSTCODE…………...
TELEPHONE MOBILE EMAIL
…………………………. ………………………… ……………………….
AUTHORITY TO PAY
Bank, Building Society or Credit Union
FULL NAME:
TAX FILE NO:
LOCATION:
I hereby authorise the Legal Aid NSW to remit:
a. My fortnightly salary; and
b. Any other payments due to me;
into the following financial institution:
Name: (e.g. Commonwealth Bank / SGE Credit Union)
If it is a bank, please specify whether it is a:
Trading or Savings Bank (tick whichever is the appropriate)
Branch / Location:
Account Name:
Branch Number (BSB Number):
Account Number:
Type of Account (ie Keycard, Everyday Savings Account etc)
All amounts remitted on my behalf pursuant to this authority shall be deemed to be payments
to me personally.
This authority is to continue until such time as it is withdrawn by me in writing.
Signature: Date: ....... / ....... / 20 .......
HEALTH DECLARATION FORM
The following information will be treated in strictest confidence and is required to assist Legal Aid
NSW in providing a safe and healthy work environment for their employees and so by using risk
management principles, determine if a pre-placement health assessment is necessary prior to your
entry on duty in the position.
Name:
Address:
Position:
Duties of the Position:
I have read the inherent job requirements and job demands for the position, which are set out in the
statement of duties/position description and the advertisement and these requirements have been
explained to me at interview.
I declare that (Please tick the appropriate statement(s) below):
I am not aware of any health condition, which might interfere with my ability to perform the
inherent job requirements and job demands of this position.
I have a health condition that may require the employer to provide me with services or facilities
(adjustments) so that I can successfully carry out the inherent job requirements and job
demands of the position.
I understand that adjustments to the workplace can be made to assist employees with
disabilities in carrying out the inherent job requirements and job demands of the position. Any
adjustments I need have been discussed with the organisation prior to completing this health
declaration.
I no longer wish to be considered for this position.
I am aware that any false or misleading statements may threaten my appointment or continued
employment.
Signature: Date:
Equal Employment Opportunity (EEO) Data Collection
Completion of this form is voluntary. We ask for your co-operation. All information provided
will be held in confidence and will only be used for the EEO Annual Report and Workforce
Profiling.
NAME: ……………………………………………………………..
SERIAL NUMBER (if known): ……………………………………..
Q1. Are you female or male?
Female
Male
Q2. Are you Aboriginal or Torres Strait Islander?
An Aboriginal or Torres Strait Islander is a person of Aboriginal or Torres Strait Island Decent,
who identifies as such and is accepted as such by the community in which he or she lives.
If you are both Aboriginal and Torres Strait Islander, please mark both “Yes” boxes.
Yes, Aboriginal Please go to Question 5
Yes, Torres Strait Islander Please go to Question 5
No
Q3. Are you from a racial, ethnic or ethno-religious group which is a minority in
Australian society?
You should answer “yes” to this question if you are a minority because of any of the following:
your language background or accent
your religion or culture
your ethnic or racial appearance
your country of birth or descent
Yes
No
Q4. What language did you first speak as a child?
English
Other language
Q5. Are you a person with a disability?
You should answer “yes” to this question if you have any one or more of the following
limitations or restrictions listed below:
a long term medical condition or ailment
speech difficulties in your native language
disfigurement or deformity
a psychiatric condition
head injury, stroke or any other brain damage
loss of sight or hearing
incomplete use of any part of your body
blackouts, fits or loss of consciousness
restriction in physical activities or in physical work
slowness at learning or understanding
any other condition resulting in a restriction
Yes
No
If “no”, you do not need to answer any more questions. Thank you.
If yes, do you require adjustments to be made at work?
You should answer “yes” to this question if your disability would make it necessary to change
any of the following:
the tasks of the job
the workplace or work area
how others behave towards you at work
the equipment you use
your working hours
Yes
No
Q6. What is your highest education level?
Withdrawn
Doctorate Degree
Master Degree
Graduate Diploma or Graduate Certificate
Bachelor Degree
Advanced Diploma or Associate Degree
Certificate
HSC or equivalent
Less than Year 12 or equivalent
THANK-YOU FOR COMPLETING THE EEO INFORMATION
