Application Form
(All fields are required)
1. Advertising Avenue:
Where did you see this role advertised?
2. Legal Work Status:
Are you legally entitled to work in New Zealand
3. Legal Work Status:
If you are not a NZ resident, please state below what type of work visa you hold and what date it expires. (Please include a copy with your application).
4. Driver's Licence:
Please select the option that best describes your driver's license status
5. Declaration of injury/or pre-existing condition that may affect you in this role.:
Do you suffer from any illness, injury or other disability which may adversely affect your work performance, regular attendance at work, personal safety of yourself or others?
6. Declaration of injury/or pre-existing condition that may affect you in this role.:
If you have answered 'Yes' to the above question, please provide details below. If you answered 'No' please enter N/A.
7. Declaration of injury/or pre-existing condition that may affect you in this role.:
Should your application be successful, would you agree to attend a Registered Health Professional nominated by the South Taranaki District Council if required.
8. Health and Safety:
STDC requires all new employees to undergo a pre-employment screening which includes a drug and alcohol test and police criminal history check. Do you consent to undertaking a pre-employment screening?
9. Health and Safety:
If you answered 'No' to the above question, please provide the reason why. If you answered 'yes' to the above question, please insert N/A.
10. Court Convictions:
Have you ever been convicted in a court in New Zealand or any other country?
11. Court Convictions:
Are there any charges against you yet to be heard?
12. Court Convictions:
If you have answered 'Yes' to either of the previous two questions, please provide brief details below. If you answered 'No' please enter N/A.
13. Financial:
Have you entered into bankruptcy or any material accommodation with creditors?
14. Financial:
If you have answered 'Yes' to the above question, please provide details below. If you answered 'No' please enter N/A.
15. Other:
Are there any other issues, such as disciplinary or dismissal matters you should declare to us in order for us to be fully informed when making the selection decision.
16. Information:
If you answered 'Yes' or 'Unsure' above, please provide further details below. If you answered 'No' please enter N/A.
17. Start Date:
Should you be successful in securing this position, how much notice are you required to provide to your current employer.
18. Work Referees:
Please nominate two people able to comment on your ability to perform the duties of the position applied for. These must be previous Supervisors or Managers (Please provide: Name, Address, Phone and Relationship to applicant).
19. Work Referees:
Can the above referees be contacted for reference checking purposes and be authorised to disclose such information that may be required.
20. Declaration:
I declare that the information provided in this application and CV, is correct. I understand that falsification; deliberately misleading; or, suppression of information, will be grounds for instant dismissal.
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