CONFIDENTIAL

Application for Employment

ACADEMIC STAFF

·  This information is being collected to enable St Cuthbert's College to recruit the most suitable person for the position below. It is therefore to be personally completed and signed by the applicant. All information provided will be treated in accordance with the Privacy Act 1993.

·  A current curriculum vitae may accompany this form outlining professional experience, personal strengths, interests, etc and elaborating on information given on this form.

·  You should also include a letter outlining your reasons for applying for the position and what you think you can add to St Cuthbert's College.

·  We thank you for taking the time to complete our application form and appreciate your interest in St Cuthbert’s College.

Position:

Please indicate which role/s you are applying for:

Surname: First Names:

Address:

Telephone Number(s): Work: Home:

Mobile Phone:

E-mail Address:

Eligibility

I am legally eligible to work in New Zealand by virtue of being:

A citizen of New Eligibility

I am legally eligible to work in New Zealand by virtue of being:

A citizen of New Zealand

A permanent resident of New Zealand

A holder of a current Work Permit

Expiry date for my work permit is

[Evidence of your right to work will need to be sighted if short-listed for interview].

Health

Have you any injuries, disabilities or medical conditions which would prevent or restrict you from performing any aspects of the job for which you are applying, or that the job is likely to exacerbate? / Yes No
Have you ever suffered from any overuse injuries, eg RSI OOS? / Yes No
Are you taking any drugs or medicine which would prevent or restrict you from performing any aspects of the job for which you are applying? / Yes No

If you have answered yes to any of the questions above, please give details:

To assist us to assess your condition and the possible effects of the position on your health, would you be prepared:

a)  To have a medical examination by a doctor nominated by the College and at its expense?

Yes No

b)  Are there any special services or facilities, which we could provide to help you carry out the work duties?

Yes No

Please identify:

Education and Training

Education:

Technical or Special Qualifications:

Experience in Teaching with Information and Communications Technology

Details:

Experience in teaching the International Baccalaureate Diploma Programme

Details:

Teaching with Information and Communications Technology Professional Development Undertaken

Details:

Recent General Teaching Professional Development Undertaken

Details:

Teacher Registration No: Expiry Date:

Teacher Registration Category: Full

Provisional

Subject to Confirmation (STC)

Professional Bodies

The Ministry requires you to disclose all previous findings made against you by any professional body in relation to your work (eg NZ Teachers Council)

Have there been any findings against you? Yes No

If ‘yes’ please provide details:

Are there any matters concerning you currently before any professional body?

Yes No

If ‘yes’ please provide details:

Secondary Jobs

If offered the job you are applying for, will you concurrently hold any secondary jobs?

Yes No

If ‘yes’ please provide details:

Additional Information:

When are you available to start?

Do you have a spouse, partner, relative, or household member working at St Cuthbert’s College or at another school? Yes No

If ‘yes’ please provide details:

Do you have a daughter attending St Cuthbert's College Yes No

Have you ever worked for St Cuthbert’s College or any other school under a different name? Yes No

If ‘yes’ please provide details:

Previous Employment: (Show most recent employer first)

1.  Name and address of employer:

From: To:

Position Title:

Duties:

May we contact this employer Yes No

2.  Name and address of employer:

From: To:

Position Title:

Duties:

May we contact this employer Yes No

3.  Name and address of employer:

From: To:

Position Title:

Duties:

May we contact this employer Yes No

Referees (Preferably previous employers):

1.  Name:

Position:

Company:

Phone:

2.  Name:

Position:

Company:

Phone:

3.  Name:

Position:

Company:

Phone:

The College will be contacting these people and by providing their details you are agreeing to this. The College will contact these people on a confidential basis and you will not be entitled to access this information.

Declaration and Authorisation

If unsuccessful, I authorise the College to keep this application for 12 months from our last contact for consideration for any future vacancies.

Yes No

I declare that the information provided on this form and any supplementary information provided in support of my application is true and accurate and provides a balanced and complete view of the details relevant for considering me for employment.

I understand that any incorrect, misleading or omitted information may disqualify me from appointment, or if appointed, that my employment may be terminated.

Signature of Applicant Date

2

J:\HR lists and Forms\Application Form 2009 Academic Staff.docx