EDUCATION and QUALIFICATION - Please Enter Name of Education organisation, years attended of highest qualification achieved
If yes, give brief details
Address
Name:
*
How many days absence in your last 12 months of employment were stated by you or a medical practitioner to be due to sickness, injury and/or accident?
0-2
3-5
6-10
11-15
16-20
>20 days
By entering your name here, you are electronically signing the form
*
Length of Service: (From - To)
ADDITIONAL INFORMATION - Do you have any additional information you consider relevant to the organisation’s decision-making concerning hiring you for this position? For example, achievements, interests, aspirations, one-off commitments (e.g. for which you will require leave) or other background information pertinent to this position etc. If so, please attach all such information to this application form.
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The position applied for requires that personal protective equipment be used/worn while carrying out tasks associated with this postion. Are you aware of any reason why you may not be able to use/wear the equipment?
Yes
No
Position Held
Position applied for
In accordance with company policy and/or at the direction of the company or authorised person do you agree to use/wear protective equipment?
Yes
No
Contact details - Phone
Contact details - Email
Contact details - Email
Are you a member of a territorial force unit or volunteer fire brigade?
Yes
No
Do you have a current drivers licence?
Yes
No
Do you have or are you aware of any likely commitments which may prevent you from attending your place of employment during normal work hours or affect your availability for overtime (eg sports, hobbies, special interests, education, training)?
Yes
No
Have you previously been employed by this company or in this industry?
Yes
No
Referee’s Name
If yes, what class?
Address
Thank you for contacting us! If needed, you will hear back within 48-72 hours.
Date of Birth
Contact details - Phone
Have you ever been charged with or convicted of a criminal offence?
Yes
No
Company
Reason for Leaving
Qualifications/Standard of Achievement:
Reason for Leaving
Name of Employer 2:
Do you currently have demerit points?
Yes
No
Company
Email
*
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Licence No
Position Held
Position you reported to (eg your Manager/Supervisor):
Length of Service: (From - To)
Contact details - Phone
Referee’s Name
Referee’s Occupation/Position
Have you at any time taken action against a current or former employer in order to resolve an employment dispute, including personal grievance action or other employment relationship problem.
Yes
No
Do you intend to engage in other paid or voluntary work whilst employed in this position?
Yes
No
Length of Service: (From - To)
Position you reported to (eg your Manager/Supervisor):
Name of Employer 3:
Reason for Leaving
Company
Are you awaiting hearing of any charges for driving offences?
Yes
No
Are you awaiting the outcome of any police investigation
Yes
No
If yes please specify:
Referee’s Occupation/Position
Referee’s Occupation/Position
Position you reported to (eg your Manager/Supervisor):
Contact details - Email
Do you have a spouse, partner, relative or household member working in this company or elsewhere in the industry?
Yes
No
Address
Do you have the legal right to work in New Zealand, either entitlement to permanent residence or a valid work permit? (Evidence will be required if you are interviewed for the position.)
Yes
No
Position Held
If Yes How Many
Referee’s Name
Do you agree to the medical examination and the company holding this information?
Yes
No
Address
If your application is accepted, approximately when could you commence employment?
Cell Phone
Name of Employer 1:
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