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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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Step 1 of 7
14%
Personal Details
Applicant Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Mobile Phone
*
Email
*
Date of Birth
*
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License Number
*
License Expiry Date
*
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Company Details
Do you operate under an ABN?
*
Yes
No
Business Name
*
Trading Name (If Applicable)
Company Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Company Phone
*
Tax File Number
*
ABN Number
*
ABN Expiry Date
*
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Does your business have an ACN?
*
Yes
No
ACN Number
*
ACN Expiry Date
*
Day
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Work Cover
Does your business have a Work Cover policy?
*
Yes
No
Company
*
Policy Number
*
Policy Expiry Date
*
Day
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Bank Payment Details
Bank
*
Branch
*
Account Name
*
BSB Number
*
Account Number
*
Are you GST Registered?
*
Yes
No
Next of Kin
Contact 1
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Mobile Phone Number
*
Home Phone Number
Work Phone Number
Contact 2
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / 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
*
Day
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GVM
*
Tare
*
Payload
*
Weight
*
Equipment
*
If none type N/A
Does your vehicle have insurance?
*
Yes
No
Insurance Company
*
Policy Number
*
Policy Expiry Date
*
Day
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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
*
First
Last
Personal Physician Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / 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
*
First
Last
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