EMPLOYMENT APPLICATION FORM

Position Being Applied For:

Location:Victoria Early Learning Centre, Gisborne

MrMissMrsMsName:______

1.CONTACT DETAILS:

Address:______

City:______Date of Birth:______/______/______

Telephone Number:(hm)______(wk)______

(mobile)______email address______

Emergency Contact Details:Name:______Telephone Number: ______

2.RESIDENT STATUS:

Are you legally entitled to work in New Zealand?YesNo

Are you a New Zealand Citizen?YesNo

I undertake to provide evidence of my permanent residency or work visa within 24 hours of being requested to do so

3.EMPLOYMENT HISTORY:

Please give details of your employment history (a minimum of five years)

Company:______From:To:

Address:______

Position Held:______

Main Duties:______

Reason for leaving:______

Company:______From:To:

Address:______

Position Held:______

Main Duties:______

Reason for leaving:______

Company:______From:To:

Address:______

Position Held:______

Main Duties:______

Reason for leaving:______

4.WORK RELATED REFEREES:

Please provide the names of two work related referees who may be contacted for a reference check. Preferably these should be people who you have reported to and they will not be contacted without you being notified.

Current or most recent employer:Previous employer:

Name:______Name:______

Address:______Address:______

Phone Number/s:______Phone Number/s:______

5.EDUCATION:

Only complete this section if the information is not included in your curriculum vitae

Secondary School / Location / Years Attended / Qualification Achieved
Tertiary Institution

6.Education Council Certification

Certification Details: Year of Certification:______Certification No. ______

7.General

Are you an existing member of KiwiSaver / YesO
NoO
If you are a member of KiwiSaver, are you on a Contributions Holiday
If yes, please give details e.g. expiry date of holiday ______/ YesO
NoO
Are you member of a territorial force or volunteer fire brigade? / YesO
NoO
Do you smoke at work? / YesO
NoO
Are you prepared to work overtime? / YesO
NoO
Do you know anyone who works at Victoria Early Learning Centre? / YesO
NoO
How many days absence due to sickness have you claimed in the last 12 months of employment? (please circle)
0-23-56-1011-1516-20Over 20 days
Are you involved in any activities that would be considered a conflict of interest with Victoria Early Learning Centre?
If yes, please provide details ______/ YesO
NoO
Have you ever been charged with or convicted of a criminal offence that is not concealed under the Criminal Records (Clean Slate) Act 2004?
If yes, please provide details______/ YesO
NoO
Are you awaiting the hearing of charges in a civil or criminal court of law?
If yes, please give details______/ YesO
NoO
Do you agree to undergo a pre employment medical and drugs test if required? / YesO
NoO
Do you have any injury or illness that may affect your ability to effectively carry out the functions and responsibilities of the position applied for / YesO
NoO
Are you allergic to, or have any sensitivity to any substances or chemicals? / YesO
NoO
Have you ever had any injury (e.g. back) or medical condition caused by gradual process, disease or infection (e.g. hearing loss, sensitivity to chemicals, muscle fatigue syndrome (OOS)) that may affect your ability to carry out the functions and responsibilities of the position applied for or impact on the company, its business or staff? / YesO
NoO
Have you claimed accident compensation in the last 12 months?
If yes, please give details______/ YesO
NoO
Do you wear corrective lenses or contact lenses? / YesO
NoO
Has your work ever been affected by stress or mental health problems (e.g. depression, anxiety)?
If yes, please give details ______/ YesO
NoO
Haveyou ever suffered from long term fatigue or tiredness that has affected your work? / YesO
NoO
Do you have any other condition which may affect your ability to effectively carry out the functions and responsibilities of the position applied for?
If yes, give details ______/ YesO
NoO
Have you ever been dismissed from your employment?
If yes, please give details ______/ YesO
NoO
I consent to the company seeking verbal or written information about me from my previous employers named and/or referees and authorise the information sought, to be released to relevant parties involved in the recruitment of this position. / YesO
NoO
I consent to the company retaining, for 12 months, the information contained in this application form, for the purposes of considering mysuitability for any other position which may arise with this company in the future? / YesO
NoO

8.Declaration

I agree and accept that by undertaking certain tasks appointed by Victoria Early Learning Centre that it does not constitute a job offer or the commencement of employment and I hereby accept that this is part of the job interview.

Declaration:

I declare that:

My answers in this application are true and not misleading: and

There is no information that may be relevant that I have not told you about.

I acknowledge that:

If I am employed, you are relying on the truth and completeness of my answers and therefore;

If, in the Victoria Early Learning Centre opinion, I have not answered truthfully and completely, my employment may be terminated immediately and without notice.

I understand that:

False or incomplete answers relating to my medical history could mean that I may compromise my access and receipt of ACC compensation.

Signed:______Date of application:______

Candidates Please Note:

The personal information you provide in this document will be held by Victoria Early Learning Centre for a period of no more than three months unless you consent to it being held for longer (as per the declaration section above) and will be used for the purpose of assessing your suitability for employment. It will be accessed by only those involved in the recruitment process. You have a right of access to this information to ensure its accuracy. This is a confidential document subject to the Privacy Act 1993.

Employment Application FormPage 1 of 4