REGISTRATION FORM POSITION APPLIED FOR: PERSONAL DETAILS Name:Collins Chabala Manselo 28/11/85 Home Address: 2316, Ndeke Changa Changa Email: [email protected] Contact Mobile: +260962109564 Marital Status: Married Nationality: Zambian 2P067990 EMERGENCY CONTACT Name(Emergency Contact 1): Maria Zulu Relationship: Wife Contact Number: +260963776519 Home Address: 2316, Ndeke Changa Changa Name (Emergency Contact 2): Mwila Elias Manselo Relationship: Brother Contact Number: +260771433111 Home Address: Mushili Bonano, TRAVEL TO OTHER COUNTRIES, In the last 10 years have you visited any countries outside of their usual country of residence? No BRUDEN Date of Birth: Home Number: Nil Passport Number: Email Address: Nil Email Address: Nil Reason for Travel _ Country Length of Stay Holiday - at i Work Others (e.g. business, etc) Reason for Travel Country Length of Stay ii Hotida iWork _ Others (e.g. business, etc) Note: please ingert another page to add more information Where you stayed for more than 12 months, within the 10 years for employment, are you able to obtain police clearance? Yes It your answer is no, please state your reason EMPLOYMENT Please list your previous employment within the last ten (10 years please insert another page for additional information. 4. Name of Employer: Ms Sharmroc Zambia Ltd Position Held: Artisan HD Machanic Length of Employment: 10 months ‘Address/Location: Luanshya Contact Number: 2. Name of Employer: Mopani Copper Mines Plc Position Held: Artisan Heavy Equipment Repair Length of Employment: 2 years 11 months Address/Location: Private Bag 22000, Kitwe, Copperbelt Zambia Contact Number: Email Address: 3. Name of Employer: Group R Mining and Exploration, Zambia Position Held: H.E.R. Fitter Length of Employment: 1 year ‘Address/Location: S.0.B. Mopani Copper Mines Plc Contact Number: +260963595349 Email Address: z 4. Name of Employer: NFC Africa Mining Plc Position Held: DS1 Assistant Operator Length of Employment: 7 months Address/Location: P.O Box 22592, Enos Cliomba Road Kitwe Contact Number: +260-2-721320BRUDENS Email Address: www.nfca.com.cn 5. Name of Employer: AAC Mining Executors Ltd Position Hel Employment: 1 year ‘AddressiLocation: $.0.B. Mopani Copper Mines Pic ‘Contact Number: +260967530313 Email Address: ‘Are you able to provide employment evidences in the last 5 years? Yes MEDICAL HISTORY Please answer the following questions regarding health. (a) Have you been hospitalised in the last 12 months? (b) Have you undergone major operation within 5 years? (c) Has any applicant ever had or currently have tuberculosis or had a chest X-ray which showed an abnormality? No (c)Has any applicant ever been in close contact at home or at work with @ person who has or had tuberculosis? (a) Does any applicant have any of the following health conditions: () Blood Disorder (i) Cancer i) Heart Condition (iv) Hepatitis B or C (v) Liver Disease (wi) Kidney Disease (vil) Mental illness (wil) Pregnancy (ix) Respiratory illness (0) HIV Infection (xi) Diabetes (ai) Disability (ai) Other Please state other conditions: (e) Are you taking any medications? Please provide information MEDICAL DECLARATION hereby declare that the above are true and correct to the best of my knowledge and | can say that | ‘am physically and mentally fit to work HD Foreman Length No No No No No No No No No No No No No ofBRUDENS Name: Manselo Chabala Collins Signa 21/03/2023 CHARACTER QUESTIONNAIRE Please answer the following questions regarding character: (1) Have you applied for a Police Clearance Certificate in the last 12 months? (2) Have you previously been in Immigration Detention? (3) Have been convicted of a crime or offence” in any country (including any conviction removed from official records)? "Ts may incude afc ard tner non criina fences ifn doubt click yes. (4) Have you been charged with any offence” in any country that is currently awaiting legal action? (5) Have been the subject of an arrest warrant? (6) Have you been found guilty of @ sexually based offence? involving a child (including where no conviction was recorded) ? (7) Have you ever been named on a sex offender register? (8) Have you been imprisoned? (8) Have you ever provided any information or a document to the * ‘Australian Immigration or Customs authorities which was wrong, incorrect, false, or misleading? (10) Have you been refused a visa or entry permit for any country (including Australia)? (11) Have you been removed or deported from any ‘Country tlnchading Austra)? APPLICATION CHECKLIST To be considered for shortlisting, please submit 1. Resume/cv ‘* must be in PGS Word Format (Template attached) ‘= Must have no gap (mention period of unemployment and reason of unemployment) 2. Video introduction - Content should have: No No No No No No No No Nov wv v @ BRUDENS Name and age Position applied for Skills and experience Family Future plan in Australia 3. Employment Evidence in the last 5 years in company letterhead ~ must have: v ei s Position title Period of employment Job description Name of company Company Address Company representative signature Date