Application Form
(All fields are required)
1. Advertising Avenue:
Where did you see this role advertised?
2. Residency:
Are you a NZ resident?
3. Residency:
If you answered 'No to Question 1, do you have the legal right to work in New Zealand?
4. Experience:
Do you have a recognised qualification in Health and Safety?
5. Experience:
If you answered 'Yes' to the above question please provide details below or put N/A if you answered 'No'.
6. Experience:
Do you have experience in Occupational Health and Safety Legislation, Hazard Management, Accident Prevention, Accident Investigation and safety culture change initiatives?
7. Experience:
If you answered 'Yes' to the above question please provide details below or put N/A if you answered 'No'.
8. Experience:
Have you been involved in undertaking an ACC workplace or similar safety audit process?
9. Experience:
If you answered 'yes' to the above question, please provide a description of your involvement below. If you answered 'No', please put N/A.
10. Experience Safety Systems:
Do you have experience in contractor safety?
11. Experience Safety Systems:
If you answered 'yes' to the above question, please provide a written description below. If you answered 'No' please put N/A.
12. 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?
13. Declaration of injury/or pre-existing condition that may affect you in this role.:
If you have answered Yes to the above question, provide details. If you answered 'No' please put N/A.
14. 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 as and when required and also undergo a drug and alcohol pre-employment test?
15. Driver’s Licence:
Please describe your driver license status
16. Court Convictions:
Have you ever been convicted in a court in New Zealand or any other country?
17. Court Convictions:
Are there any charges against you yet to be heard?
18. 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.
19. 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.
20. 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).
21. Work Referees:
Can the above referees be contacted for reference checking purposes and be authorised to disclose such information that may be required.
22. 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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