Personal Information

Employment History



IMPORTANT: Failure to provide full and accurate information may result in the denial of any future workers’ compensation claim in accordance with Section 79 of the Workers Compensation and Injury Management Act 1981, as amended, which states: "where it is proved that the worker has, at the time of seeking or entering employment in respect of which he/she claims compensation for a disability, willfully and falsely represented themselves as not having previously suffered from disability, a dispute resolution body may in its discretion refuse to award compensation which otherwise would be payable.


Please note: allowed file types are doc, docx, odt, pages, rtf, txt & pdf and the maximum size per file is 3 MB.


I certify that the information supplied in this Employment Application is true and correct. I understand that false, misleading or non disclosure of information may result in possible disciplinary action including termination of employment.