Online Form - Work Experience Application

Thank you for considering the Shire of Wyndham East Kimberley in your endeavour to obtain Work Experience. Please complete this form, collate your supporting documents and provide to the Shire.

Personal Details

Please Choose an Option*

Surname/ Family Name*

Given Names*

Postal Address

Postal Address:*

City:*

State:*

Post Code:*

Country:*

Residential Address

Street Address:

City:

State:

Post Code:

Country:

Email*

Contact Number - HOME

Contact Number - MOBILE*

Date of Birth*

Name of School/ Institution*

Contact Name*

Contact Email*

Contact Number*

School Year

Tafe Level

University Year

Placement Details

Area of Interest*

Please outline the timeframe of work you are seeking (eg. 2 days per week for 6 weeks)*

Preferred work experience time from

Preferred work experience time to

Preferred work experience days*

Monday
Tuesday
Wednesday
Thursday
Friday

Preferred Commencement Date*

Preferred Finish Date*

Additional Comments (if required)

Additional Details

To assist in assessing opportunities for your placement in the appropriate type of work, please indicate whether you have a disability or injury likely to affect your ability to perform tasks, which could reoccur or be aggravated by the type of work experience that you are applying for*

YesNo

Emergency Contact Name*

Emergency Contact Number*

Supporting Documentation

Insurance Document

You must provide a copy of your school, university, institution or organisation’s insurance Certificate of Currency with your application – this provides SWEK with proof of insurance coverage during placement.

Insurance Document File Upload*

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

Confirmation of Approval/ Support

Your school, university, institution or organisation will need to provide written confirmation of their support/approval for your application and confirm that it relates to your current educational/career pursuits.

Note - if you are aged between 15 -17 you will need to provide written confirmation from your parent/guardian.

Confirmation of Approval/ Support File Upload*

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

Parent/ Guardian Approval Letter File Upload (if required)

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

Declaration

Please type your name below to signify that you agree that all information given above is true and correct at the time of submission*

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