Application For Employment - Airlink Page 2
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1
2Application for Employment
Employer
Type of business
Address
Position held
Type of responsibilities
Salary
Reason for leaving
MEDICAL HISTORY
General
Yes
No
Are you currently taking any medication or treatment requiring a strict timetable?
Have you in the past received compensation for any industrial injury or illness?
Have you ever had an illness/accident that caused you to be absent from work for more than 3 months?
Have you been absent from work for any medical reason for more than 10 days in the past year?
Have you ever had to give up any previous job for medical reasons?
Do you wear glasses/contact lenses?
Have you in the past been involved in an aircraft related accident
Have you been exposed to any of the following
Yes No
Yes
No
hazards?
Lead
Chemicals
Vibration
Excessive Noise
Tar
Excessive Dust/Fumes
Radiation
Compressed Air Conditions
Asbestos
Other (please specify)
Have you ever suffered from any of the following?
Yes No
Yes
No
Heart Disease
Deafness
Blood Pressure
Asthma
Back Pain
Poor Vision
Psoriasis
Abdominal Complaint
Eczema
Urinary Disorder
Migraine
Seizures/Blackouts
Allergies
Stomach Ulcer
Lung Disease
Ear Disease
Jaundice
Eye Disease
Joint Pain
Kidney Disease
Diabetes
Other (please specify)
I confirm that the above information is true and correct.
Print name:
_________________________
Signature: ______________________
Date: ________________________
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Parent category: Business