Please enter details in the form below if you would like to make an online JobFit System PEFA request.

If you have any questions before or whilst you are completing this form, please contact us at 1800 JOBFIT. 

We look forward to being of service to you.

Your Name:	*
Your Company:	*
Your Site:	*
Your Phone (Business Hours):	*
Your Phone (After Hours):
Your Email:	*
Worker Details
Worker Name:	*
Worker Phone (Mobile):	*
Worker Phone (Home):
Worker Phone (Work):
Worker Email:
Job Details
Job Title:	*
Due Date:
Preferred location for PEFA:	Please Select --QLD-- BlackwaterBrisbaneBundabergCairnsDysartEmeraldGladstoneGlendenGold CoastHervey BayIpswichMackayMiddlemountMoranbahMouraMt IsaRockhamptonSpringsureTieriToowoombaTownsvilleYeppoon--NSW--CharlestownForsterGosfordMudgeeNewcastleParkesSydneyTamworthYoung--VIC--MelbourneWodonga--ACT--Canberra--NT--Darwin--SA--Adelaide--WA--PerthPort HedlandTom Price--TAS--Hobart--OTHER-- *
Alternative location preference:	Please Select --QLD-- BlackwaterBrisbaneBundabergCairnsDysartEmeraldGladstoneGlendenGold CoastHervey BayIpswichMackayMiddlemountMoranbahMouraMt IsaRockhamptonSpringsureTieriToowoombaTownsvilleYeppoon--NSW--CharlestownForsterGosfordMudgeeNewcastleParkesSydneyTamworthYoung--VIC--MelbourneWodonga--ACT--Canberra--NT--Darwin--SA--Adelaide--WA--PerthPort HedlandTom Price--TAS--Hobart--OTHER--
Reason for referral:	Pre-employment – new Pre-employment - transfer Periodic – injury (med cert required) Periodic – other
Is this candidate under 18 years of age Yes    No
Other	Anything else you think we should know (eg. Preferred location for assessment, need to fit in with doctor appointments, going on holidays, change in company doctor etc):
	To keep you informed of progress, several confirmation emails will be sent to you 1. Confirmation of receipt of referral 2. Confirmation of appointment 3. Confirmation of report sent

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