Driver Application Form - Rush Express

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20 Tarlington Pl, Smithfield NSW 2164

Don't Just Send It! Telephone: 1300 787-448 E-mail: sales@rushexpress.com.au

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Driver Application Form

Step 1 of 7

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Personal Details
Applicant Name*
FirstLast
Address*
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal Code
Mobile Phone*
Email*
Date of Birth*
License Number*
License Expiry Date*

Company Details
Do you operate under an ABN?*
- Yes
- No
Business Name*
Trading Name (If Applicable)
Company Address*
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal Code
Company Phone*
Tax File Number*
ABN Number*
ABN Expiry Date*
Does your business have an ACN?*
- Yes
- No
ACN Number*
ACN Expiry Date*
Work Cover
Does your business have a Work Cover policy?*
- Yes
- No
Company*
Policy Number*
Policy Expiry Date*

Bank Payment Details
Bank*
Branch*
Account Name*
BSB Number*
Account Number*
Are you GST Registered?*
- Yes
- No

Next of Kin
Contact 1
Name*
FirstLast
Address*
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal Code
Mobile Phone Number*
Home Phone Number
Work Phone Number
Contact 2
Name*
FirstLast
Address*
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal Code
Mobile Phone Number*
Home Phone Number
Work Phone Number

Vehicle Details
Vehicle Type*
- Ute
- Van
- Hatchback
- Ridged Sized Truck
- Station Wagon
Vehicle Make*
Vehicle Model*
Vehicle Year*
Vehicle Class*
Company Driver*
- Yes
- No
Vehicle Registration Number*
Vehicle Registration Expiry Date*
GVM*
Tare*
Payload*
Weight*
Equipment*
If none type N/A
Does your vehicle have insurance?*
- Yes
- No
Insurance Company*
Policy Number*
Policy Expiry Date*

Application For Engagement As a Subcontractor / Haulier
Pre-Engagement Medical Questionnaire
Do you play sports?*
- Yes
- No
What sport/s do you play?*
Do you have a personal physician?*
- Yes
- No
Personal Physician Name*
FirstLast
Personal Physician Address*
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal Code
Have you ever been?
Seriously Injured?*
- Yes
- No
Refused employment for health reasons?*
- Yes
- No
On workers compensation/work care/work cover*
- Yes
- No
Refused Life Insurance?*
- Yes
- No
Refused a drivers license*
- Yes
- No
Attended by a chiropractor?*
- Yes
- No
Do you have any allergies to
Solvents*
- Yes
- No
Dust*
- Yes
- No
Oils*
- Yes
- No
Other Allergies*
If none, type N/A
Have you ever
Injured your back*
- Yes
- No
Had a head injury*
- Yes
- No
Had a hernia or rupture*
- Yes
- No
Had nerve trouble*
- Yes
- No
Taken medicine regularly*
- Yes
- No
Suffered from high blood pressure*
- Yes
- No
Suffered from fainting spells or dizziness*
- Yes
- No
Had shortness of breath*
- Yes
- No
Suffered from heart trouble*
- Yes
- No
Had joint pain or stiffness*
- Yes
- No
Suffered from any hearing impairment*
- Yes
- No
Are you aware of any existing or pre-existing medical condition that would affect your duties as a sub-contractor to Rush Express?*
- Yes
- No
Details*

Terms & Conditions
I*
FirstLast
On behalf of*
Company Name
*
- I agree that dkcb Pty Ltd T/as Rush Express shall not be liable in any respect if my engagement as a contractor is terminated because of falsity of statements, answers or omissions wilfully made by me in the questionnaire.
*
- I also state that I have received the dkcb Pty Ltd T/as Rush Express operating manual / OHS / Policy & Procedures manual.
*
- I fully accept the terms and conditions Rush Express have provided

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