EMPLOYMENT APPLICATION

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Personal Details

Are you a NZ Citizen:

If not please supply a copy of your work permit and/or permanent residency certificate.

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Do you hold a N.Z. Drivers Licence:
Have you ever been convicted of a driving offence or do you have any charges pending?
Have you ever had any other criminal convictions or do you have any charges pending?
Have you ever been the subject of a professional disciplinary enquiry by a professional group which resulted in any form of adverse finding, censure or ruling?
Are you prepared to work overtime if required:

Education Details

Employment History

CURRENT EMPLOYMENT

Are you currently employed:

PAST EMPLOYMENT

Repeat as required...

SECONDARY EMPLOYMENT

Do you have any secondary employment:

Medical History

Have you made a claim to ACC within the last 5 years?
Have you had or do you currently have any injury or medical condition caused by gradual process, disease or infection, for example; hearing loss, sensitivity to chemicals, occupational overuse injuries, back injuries, that may be aggravated by this position or affect your ability to carry out the functions of the position applied for?

Referees

CURRENT EMPLOYER

For the purposes of compliance with the Privacy Act 1993 do you consent to Company contacting your present employer for the purposes of reference checking?

PREVIOUS EMPLOYMENT

Please provide the names, addresses and contact telephone numbers of three people who will provide work references for you and who you authorise us to contact for this information.

Your Signature

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