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Job Application

What position are you applying for? *
First name *
Last name *
Home address
Daytime phone number *
Mobile or other
Email address *
Do you hold a current driver licence * Yes No

Qualifications and employment history

Qualifications *
Relevant papers/subjects *
From *
To *
Add Qualification

List of any relevant training that you have completed.

Course
Relevant papers/subjects
From
To
Add Course

Provide details of your present and previous employment. Please complete in full.

Name and address of employer *
Position and main duties *
Reason for leaving *
Can we contact the employer? *
From *
To *
Add Employment

Legal requirements

Are you entitled to work in NZ? * Yes No
If yes, are you legally entitled to work because: * You are a NZ Citizen You have a Work Visa Other? (please explain)
If other, please explain
Attach Visa
(Document supplied must be in .pdf or .docx format)
Expiry date of Work Visa

Disabilities or Medical Conditions

Note: The Human Rights Act 1993 defines disability as: physical disability or impairment; physical illness; psychiatric illness; intellectual or psychological disability or impairment; the presence in the body of organisms capable of causing illness; any other loss or abnormality of a body or mind function; and reliance on a guide dog, wheelchair or other remedial means.

Do you have any disability or medical condition that may affect your ability to fully and effectively carry out the tasks and responsibilities described in job specification? * Yes No
If yes, please provide details (please include any services or facilities which would allow you to carry out this role satisfactorily)
Do you have, or have you had, any injury or medical condition caused by a gradual process, disease or infection which may be aggravated by the function and responsibilities of the job for which you have applied, and it is described in the attached job specification? * Yes No
If yes, please provide details:
Do you have any present or past injury for which you may or may not have claimed ACC and/or other insurance cover, which may be aggravated by the job you have applied for? * Yes No
If yes, please provide details:
Have you suffered from any injury to your neck, shoulders or back? * Yes No
If yes, please provide details:

Criminal History

I understand that any record of criminal convictions I might have will automatically be concealed if I meet the eligibility criteria stipulated in Section 7 of the Criminal Records (Clean State) Act 2004.

Have you ever been convicted of any criminal offence, including matters relating to dishonesty, E.G., fraud, theft, misappropriation of funds, within the last seven years? * Yes No
Are you awaiting a hearing on any charges? * Yes No
If yes, please provide details:
Attach Coverletter *
(Document supplied must be in .pdf or .docx format)
Attach CV *
(Document supplied must be in .pdf or .docx format)

Declaration and Acknowledgement

I declare that to the best of my knowledge the information that I have provided is accurate, and complete, and I have not withheld any information which may have a bearing or any relevance to my application. *
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