Applicant Details

Given Name*

Last Name*

Male Female 

Company*
- Select -Virgin AustraliaVARACobham NJSCobham NJECobham Special MissionNetworkAllianceJetstarQantasOther

If Other, please state:

Rank*
- Select -CaptainFirst OfficerSecond OfficerOther

Fleet*
- Select -B737B777A330ATR72F100E190Dash 8BAE146Other

Base*
- Select -BNEMELPERSYDCBRCNSADLOther

Salary (excl. Superannuation)*

Employee Number*

Date of Birth*

Mobile Phone*

Health Declaration

Please answer every question

1. What is your current height (cm)?

2. What is your current weight (kg)?

3. In the past 12 months, have you smoked tobacco or any other substance?
 Yes No

If Yes, please provide an explanation as to the substance smoked and the volume per day.

4. Have you ever had cancer or tumours of any type?
 Yes No

If Yes, please provide details including when this occurred.

5. Are you aware of any medical condition or issue that may require you to undergo surgery in the future?
 Yes No

If Yes, please provide details.

6. Have you ever suffered from high blood pressure, cholesterol, stroke or paralysis of any description?
 Yes No

If Yes, please provide details including when this occurred.

7. Have you ever had any cardiovascular complaint?
 Yes No

If Yes, please provide details including when this occurred.

8. Have you ever suffered from diabetes, kidney or bladder problems?
 Yes No

If Yes, please provide details including when this occurred.

9. Do you drink alcohol?
 Yes No

If Yes, how many drinks per week do you drink on average?

10. Have you ever been diagnosed with or received treatment for any mental health condition?
 Yes No

If Yes, please provide details including when this occurred.

11. Do you now have or have you ever had any disease of, or injury to, the neck or spine including back strain, disc disorder, sciatica or other non-specific back pain?
 Yes No

If Yes, please provide details including when this occurred.

12. During the last 5 years, have you taken or are you taking prescribed medication of any kind?
 Yes No

If Yes, please provide details.

13. Have you ever had more than 15 days absent from work in a 12 month period due to injury or illness?
 Yes No

If Yes, please provide details including when this occurred and the circumstances.

14. Are you currently covered by a Loss of Licence or Income Protection Policy?
 Yes No

If Yes, please provide details.

15. Have you ever claimed under any Loss of Licence or Income Protection cover?
 Yes No

If Yes, please provide details.

16. Have you ever been refused cover by a Loss of Licence insurer or Discretionary Mutual Fund (DMF)?
 Yes No

If Yes, please provide details.

17. In addition to the responses provided above, do you have any other pre-existing health conditions (injuries or illnesses)?
 Yes No

If Yes, please provide details.

Declaration and Signature

I, the Applicant, declare that I am not aware of any past or present injury or illness that may give rise to a claim for Loss of Licence benefits that has not been disclosed above, and that the above information I have disclosed is true, accurate, full and complete. I understand that if I have misrepresented or not properly disclosed any information which is requested in this form, it may affect my entitlement to hold membership of VLF, to seek protection from VLF and/or claim for Loss of Licence benefits.

Your Full Name as Signature*

Date*

By clicking Submit you indicate you have accepted the Terms and Conditions as above.