PERSONAL DETAILS:

    Position Applying For:

    Name: *

    Date of Birth: (optional)

    Contact Address:

    Contact Telephone Numbers: *

    Email Address: *

    NEXT OF KIN DETAILS:

    Next of Kin and Relationship:

    Contact address:

    Contact Telephone Numbers:

    EEDUCATION AND TRAINING

    What is your highest formal qualification? :

    List any other qualifications you have achieved / relevant training you have undertaken:

    WORK SKILLS

    Outline the relevant skills that you consider make you suitable for the position:

    Do you have a valid visa to work in New Zealand

    EMPLOYMENT HISTORY

    Unless you are a new school leaver, give details of your three most recent positions:

    Position one

    Position two

    Position three

    REFEREES

    CONFIDENTIAL: In providing references I consent to the above named employer seeking verbal or written information on a confidential basis about me from my previous employers and/or referees. I authorise the information sought to be released by them to the above named employer for the purpose of ascertaining my suitability for this position.

    MEDICAL HISTORY

    Given the physical nature of the work offered, we need the following information to assess your suitability and also to be aware of any First Aid needs should you be involved in an accident at work.

    Have you had or do you suffer from, any of the following conditions, which the tasks of this job may aggravate or contribute to?

    *Dermatitis or Eczema
    Comments :

    *Asthma
    Comments :

    *Back injury
    Comments :

    *Blackouts or seizures
    Comments :


    *Bronchitis
    Comments :

    *Colour Blindness
    Comments :

    *Eyesight
    Comments :

    *Phobia’s
    Comments :

    *Diabetes
    Comments :

    *Epilepsy
    Comments :


    *Hearing Impairment
    Comments :

    *Hernia
    Comments :

    *High blood pressure
    Comments :

    *Cardiac problems
    Comments :

    *Mental health
    Comments :


    *Recurring injuries
    Comments :


    *Occupational overuse (OOS)
    Comments :


    *Other


    Are you currently taking any prescription drugs or medication? If so; what type and what for?


    List any activities / jobs you can’t do because of health or other reasons


    Do you have any family commitments / needs which require any special allowances; that need to be catered for? *


    I agree to attend a medical practitioner when requested by the employer

    KIWISAVER


    If eligible, you will be automatically enrolled into the Government’s KiwiSaver scheme. Do you wish to opt out?

    LEGAL ISSUES


    Are you legally entitled to work in New Zealand?

    New Zealand Citizen
    Permanent NZ Resident
    Hold NZ work permit (expiry date)


    Are you awaiting a court hearing of any alleged driving or criminal offence which might affect your suitability for this position, or your ability to effectively carry out the functions and/or duties of the position applied for?


    If answer is yes, please detail


    Do you have any criminal convictions, not including any concealed under the Clean Slate Act?


    If yes, please detail


    Do you give us permission to carry out a Police check?


    As part of our Health & Safety programme, we have a zero drug and alcohol policy. If successful for a permanent position you will need to undergo a drug test. Do you have any reason to believe you would not pass a drug test now or in the future?

    DRIVERS LICENCE


    Do you have a current drivers licence?


    If yes, what classes of vehicle are you licensed to drive? (Include here if you have provisional or learner status.)


    Please upload your CV and letter of motivation here

    DECLARATION


    I declare that the answers to the questions in this application are true and correct. I understand that if any of the information is proved to be false or misleading, or any relevant information is left out on this form or any other supporting documents, e.g. CV, then this may lead to my application being rejected, or if appointed to a position, then I may be instantly dismissed.