Home Assist Contractor Application Form

Personal Information

Given Name:

Surname:

Preferred Name:

Street Address:

Suburb and Postcode:

Postal Address: If this is different to your residential address

Telephone Number:

Email Address:

COVID-19 Vaccination Status: Have you received your COVID-19 Vaccinations and Booster? As per the State Government directive, all In-Home and Community Aged Care Workers must be vaccinated against COVID-19 with a TGA Approved Vaccine. It is also a requirement to have received a Booster Vaccination. An In-Home and Community Aged Care Worker is not required to have evidence of a COVID-19 Vaccination if they have a Medical Exemption.

Please select what TGA Approved Dose you received:

AstraZeneca (Vaxzevria)
Pfizer (Comirnaty)
Moderna (Spikevax)
Novavax (Nuvaxovid)

Please select what TGA Approved Dose you received for your Booster Vaccination:

Pfixer (Comirnaty)
Moderna (Spikevax)

Business Details:

Australian Business Number (ABN):

Business Name: If Applicable

GST Registered

Are you registered with Work Cover? Please note – that if you employ any workers under your ABN, you are obligated to have workers compensation insurance

Public Liability Insurance

Do you maintain your own Public Liability Insurance? Please note, if yes, the minimum required by the Town of Gawler is $10million

Yes (Please Provide Details)
No

Insurer:

Policy Number:

Expiry Date:

Extent of Cover Per Incident ($AUD)

OR: I would like to access Principal Maintained Public Liability Insurance Please note, If a claim is made via the Principal Maintained Public Liability policy, the Contractor is responsible for the cost of any deductible excess

Drivers Licence and Vehicle Information

Drivers Licence Number:

Drivers Licence Expiry Date:

Vehicle Type:

Vehicle Registration Plate:

Vehicle Registration Expiry Date:

Does the Vehicle Belong to you?

Is the Vehicle in a safe and roadworthy condition?

Vehicle Insurance Type:

Comprehensive
Third Party
No Insurance

Car Insurer:

Policy Number:

Expiry Date:

Questions

Please provide details of your relevant skills and/or experience in delivering these (or similar) services:

Are there any other comments that you would like to make which could help demonstrate your suitability to perform the required services?

National Screening Checks, Certificates and Licences

Do you have a National Police Check or an ASIC approved screening check dated less than 3 years old? If yes, then please provide details in next questions. Please either email a copy or provide at induction stage. If no, you will be required to get an acceptable screening check prior to providing any services as an Independent Contractor. Due to funding requirement, please speak to one of the team regarding what checks are acceptable to the program.

Yes
No
In Progress

Screening Provider and Attainment Date:

Do you have a 'Provide First Aid' Certificate dated less than 3 years old? Please note, in order to provide social support services, Contractors must hold an accredited Provide First Aid Certificate. If you have indicated yes, please provide details in the next question:

Yes
No
In Progress

First Aid Provider and Attainment Date:

Do you hold any other relevant Licences or Certificates (e.g. Certificate III in Aged Care, Builders Licence, Working at Heights Certificate?

If yes to question above, please provide details of Licences/Certificates, including expiry dates, where relevant.

Emergency Contact Information

Name of Emergency Contact:

Relationship to you:

Contact Number:

Referee 1 (please provide a minimum of 2)

Name:

Organisation:

Position:

Telephone:

Email Address:

Referee 2

Name:

Organisation:

Position:

Telephone:

Email Address:

Referee 3

Name:

Organisation:

Position:

Telephone:

Email Address:

Contract Conditions

To be accepted as an Independent Contractor, you will need to attend an Interview with Home Assist Staff, present the original copy of a National Police Clearance that satisfies the requirements of the Commonwealth Home Support Programme Grant Agreement and CHSP Program Manual, attend an induction session and complete mandatory online training requirements Do you understand these conditions?

Please sign below (Print Name and Date in DD/MM/YYYY format)

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