FORM 405 Candidate Registration (Central)

DOME Incorporated collects the following required information for the purpose of auditing participation and the
monitoring and reporting of training and employment outcomes. The information you provide may be
accessed by DOME officers and government funding bodies for the above stated purposes.

Title: (Please tick ONE box only) Mr Miss  Mrs  Ms  Other  .................

Gender: (Please tick ONE box only): Male  Female 

Family Name: (Surname) .......................................................................................................................

Given Names: ...................................................................................................................................................

Date of Birth: (dd/mm/yyyy) ............/ ......... / ..............

DOME Interview - Date: (dd/mm/yyyy) ….…/……/ ........ - Time: …………………

Address of Residence:
Building /Property Name: .......................................... Flat/Unit Number:............... Street Number: ...............

Street Name: ...................................................................... Suburb:........................................................

State/Territory: ......................... POSTCODE:.....................

Postal Address: (If different from above)

Phone: Home: …………………….. Work:……………………. ……… Mobile:………………………….

E-mail: ...................................................................................................................................................

Were you born Outside of Australia  Yes  No When did you arrive? (Year)……………………

Are you registered with Centrelink?  Yes  No

Are you receiving assistance through a Job Service Agency?  Yes  No

If Yes, what is the name of the Agency? …………………………… Case Manager: .……………………..

What Assistance Level are you receiving?  Stream1  Stream2  Stream3  Stream4

How long have you been unemployed?  0 - 3 Mths  3 - 12 Mths  12 - 18 Mths

How did you hear about this program?

 Centrelink/Job Network  Training/Employment Service Provider

 Other (Please provide details)  Friend/Relative

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1. In which country were you born? 8. What is your highest COMPLETED school level?
(Tick ONE box only)
Australia .................................. 
Year 12 or equivalent 
Other (Please Specify) .................................................... Year 11 or equivalent 
2. Do you speak a language other than English at Year 10 or equivalent 
home? (If more than one language, indicate the one that Year 9 or equivalent 
is spoken most often.)
Year 8 or equivalent 
Never Attended School  Go To Question 10
English Only  Go To Question 4
9. In which YEAR did you complete that school level?
Yes, Other (Please Specify) ...................................................
.........................................................................................
3. How well do you speak English?
10. Have you SUCCESSFULLY completed any
Very Well  qualifications?
Well  Yes 
Not Well 
No  Go To Question 12
Not at All 
11. If YES, then tick ALL applicable boxes.
4. Are you of Aboriginal or Torres Strait Islander
origin? (For persons of both Aboriginal AND Torres Strait
Islander origin, please tick BOTH boxes)
Bachelor Degree Or Higher Degree 
Advanced Diploma Or Associate Degree 
No  Diploma {Or Associate Diploma) 
Yes, Aboriginal  Certificate IV (Or Advanced Certificate/Technician) 
Yes, Torres Strait Islander  Certificate III (Or Trade Certificate) 
5. Do you consider yourself to have a disability,
Certificate II 
impairment or long-term condition? Certificate I 
Certificates Other Than Above 
Yes 
No  Go To Question 7 12. Of the following categories, which BEST describes
your current employment status?
6. If YES, then please tick the areas of disability, (Tick ONE box only.)
impairment or long-term condition. (You may
indicate more than one area.) Full-Time Employee 
Part-Time Employee 
Hearing/Deaf  Self-Employed - Not Employing Others 
Physical  Employer 
Intellectual  Employed - Unpaid Worker In a Family Business 
Learning  Unemployed - Seeking Full-Time Work 
Mental Illness  Unemployed - Seeking Part-Time Work 
Acquired Brain Impairment  Not Employed - Not Seeking Employment 
Vision 
13. Your major reason for study? (Tick ONE box only.)
Medical Condition 
Other  Get a Job 
7. Are you still attending secondary school? To Develop My Existing Business 
To Start My Own Business 
Yes  To Try For A Different Career 
No  To Get A Better Job Or Promotion 
It Was A Requirement Of My Job 
I Wanted Extra Skills For My Job 
To Get Into Another Course Of Study 
For Personal Interest Or Self-Development 
Other Reasons 

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 Preferred Work Hours: Any  Full Time  Part Time  Casual 

Any days or times you may NOT be available for work? .............................................................................................

When can you start work? ………………………. Were you retrenched from your last job?  Yes  No

Would you consider moving to a regional area to work?  Yes  No If Yes which region?.............................

Do you have a current drivers licence?  Yes  No If so, what class is it?...........................................

Any special driver accreditation? (SP or LP)……………… Do you have a car?  Yes  No
Do you have any of the following:
Current First Aid Certificate  Yes  No Police Clearance  Yes  No
Any Trade Licences (Electrician, Plumber, etc)………………………………………………………………………………..
Any special vehicle licences (forklift, bobcat, etc) ……………………………………………………………………………..
Any special equipment/machinery experience?....................................................................................................................
SKILLS AND WORK PREFERENCE ANALYSIS
This section is to assist us in better understanding your current skills and interests. The interviewer will review it with
you, so please include as much information as possible.
The first section is for skills you have previously used, the second is for non work related skills/interests, which would
be helpful in identifying additional job opportunities. In the third section, list jobs you may be interested in, using your
current skills.
1. Please list the skills you have, making a self assessment of your level of proficiency
Very Good Skills: ………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………..
Good Skills: ………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………..
Limited Skills ………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………..
2. Interests and Activities: ……………………………………………………………………………………………………
……………………………………………………………………………………………………………………………….
3. Preferred Job Positions: …………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………….
Government Statistical Reporting:

Marital Status: Single  Married  De Facto  Divorced 

Nationality:………………………… Number of Dependants…..............

Are you receiving a benefit from Centrelink?  Yes  No What type?.............................................

Are interested in volunteering at DOME?  Yes  No Have you provided a resume?  Yes  No

To be completed at the interview with DOME staff

Candidates Signature: ...................................................Date: ........... / ............. /..........

Interviewers Signature:..................................................Date: ........... / ............. /..........

Donation Receipt Number…………………………..
When complete click on the send button and we will hold a copy of this form ready for your interview.
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