Application Form

Please note, the information collected is for the purpose of assessing suitability for employment and does not guarantee an offer of employment will follow.

What position are you applying for?
How did you hear about the position?

Personal Details
First Name(s):
Surname:
Postal Address:
Mobile:
Home Phone:
Email:

General

Are you a New Zealand or Australian citizen?	Yes	No
If NO, do you currently have the right to work in New Zealand?	Yes	No
Please state expiry date of work visa (Must attach copy of work visa to verify)

Do you hold a current New Zealand driver licence	Yes	No
Licence Type (please indicate)	Learner Restricted Full
Class of driver licence
Is there any matter pending which could affect the status of your Driver Licence?	Yes	No

Have you attached a copy of your CV and Cover Letter?	Yes	No

Referees

Please provide contact details for three previous managers who we can contact to discuss your suitability for this role. Referees should not be related or part of your extended family and must be from your most recent employment. Character referees are sufficient if you have not been employed previously

Referee #1
Referee Name:
Phone:
Organisation:
Relationship:
What was your position when you reported to this person?

Referee #2
Referee Name:
Phone:
Organisation:
Relationship:
What was your position when you reported to this person?

Referee #3
Referee Name:
Phone:
Organisation:
Relationship:
What was your position when you reported to this person?

Criminal History

Have you ever been convicted for any violations or offences (that are not concealed by the Clean Slate Act)?	Yes	No
Do you currently have any criminal charges pending against you or awaiting the hearing of any criminal charges?	Yes	No
If you answered YES to any of the above, please list the conviction(s) or charges(s) and approximate date received.

Conviction/Charge	Date

Medical History

Do you have any medical conditions (inclusive of diagnosable mental illnesses) or injuries that may affect your ability to perform the job adequately and/or safely?	Yes	No
If YES, please provide details below.

Declaration

I acknowledge and declare that I

have provided true and correct representations on this Application Form and not mislead Ngāpuhi Iwi Social Services in any way;

have not failed to disclose any matter that may have materially influenced Ngāpuhi Iwi Social Services decision to employ me;

have disclosed all criminal convictions or charges not covered by the Clean Slate Act, whether I consider such convictions or charges to be relevant to this application or not;

for the purposes of the Privacy Act, consent to Ngāpuhi Iwi Social Services contacting any of my past employers and referees for reference checking;

have not failed to disclose any medical conditions or injuries that may affect my ability to perform the job adequately and/or safely; and

understand that if I am successful in securing a position with Ngāpuhi Iwi Social Services and Ngāpuhi Iwi Social Services later discovers that I have mislead them in any way; including but not limited to a failure to disclose criminal convictions or charges (whether I consider them relevant or not) that a breach of trust and confidence has occurred and Ngāpuhi Iwi Social Services may take disciplinary action up to and including summary dismissal (termination of my employment without notice).

Applicant’s signature	Date