Rec4b - APPLICATION FORM

REC4b - APPLICATION FORM

1. Position
Job title: / Vacancy No:
Please attach: / □ CV □ Covering Letter
2. Personal Information
Your Title / □ Mr □ Mrs □ Miss □ Ms □ Other: ______
Family Name:
Given Name/s: / Preferred Name:
Physical Address:
Postal Address:
(if different to above)
Home Phone: / ( ) / Mobile:
E-mail Address:
Language: / Is English your 1st language: □ Yes □ No
What other language/s do you speak? ______
3. Citizenship and Right to Work
Are you legally entitled to work in New Zealand: / □ Yes □ No
If ‘Yes’ select one of the following and provide documented evidence:
□ New Zealand citizen □ Resident/Permanent resident
□ Current work permit (expiry date:______)
If on a work permit are there restrictions on the type of work you can do?
□ No □ Yes (if yes you may not be eligible to be employed by HHL Group)
4. Medical or Injury Details
Could a previous or pre-existing injury or illness be aggravated by the requirements of this position or prevent you carrying out its responsibilities? / □ Yes □ No
If yes: i) What are the full details of all your injuries/medical condition?
ii)  ii) How is your performance likely to be affected?
Please note that declaration of a medical condition will not rule you out of consideration, but you may be required to provide a medical clearance and/or to authorise ACC to release your injury history record.
5. Information for Disclosure of Criminal Convictions
Please enclose a signed copy of the relevant disclosure form:
·  Police Vetting – For roles working with vulnerable clients or a role which may involve working with children, or
·  Criminal Convictions Check (Ministry of Justice) - For all other roles
You must declare any convictions if you have:
·  been convicted of an offence within the last seven years
·  been sentenced to a custodial sentence (e.g. imprisonment, corrective training, borstal, home detention)
·  been ordered by a court during a criminal case to be detained in a hospital due to your mental condition, instead of being sentenced
·  been convicted of a “specified offence” (e.g. sexual offending against children and young people or the mentally impaired)
·  not paid in full any fine, reparation or costs ordered by the court in a criminal case
·  been indefinitely disqualified from driving under section 65 of the Land Transport Act 1988, or an earlier equivalent provision.
Please answer the following based on the above criteria.
Have you been convicted of a criminal offence? / □ Yes At least one of the criteria applies and I disclose my criminal convictions below.
□ No None of the above criteria applies to me, or I have no convictions
If you are applying for a role as a caregiver (e.g. Support Worker), the Criminal Records (Clean Slate) Act 2004 does apply. Note: non-declaration of an offence you are required to disclose will be treated as misrepresentation of a criminal record and legal action may be taken.
Offence / Year Committed / Details of fine/supervision/imprisonment
Have you been subject of a Diversion ordered by court? / □ Yes □ No
Do you have any charges pending? / □ Yes □ No
If ‘yes’, please provide details and the status of the proceedings:
6. Working with Children and Young People
Complete this section if applying to work with a child or young person under the age of 17
Have you ever been involved with, or known to Child, Youth Family Services (CYFS)? / □Yes □ No
If yes, please provide information as to what your involvement was/is:
Do you agree to allow HHL Group to contact CYFS to confirm this declaration? / □Yes □ No
Working with children requires additional security checks, do agree to participate? / □Yes □ No
7. Driver Licence
What type of driver licence do you hold? / □ Full □ Restricted □ Learners □ None
Licence expiry date: / Licence number:
Do you have any endorsements on your licence? / □ Yes □ No
If yes, what are they?
If applying for support worker role with NZCare, it is a requirement to hold a current full driver licence and have the ability to drive NZCare manual vans
Are you able to drive a manual vehicle? / □ Yes □ No
If no, it will be a condition of any NZCare employment offer that you will learn to drive a manual van; are you prepared to do so? / □ Yes □ No
8. Conflict of Interest
To ensure the organisation can operate in an impartial manner, it is necessary for individuals to:
·  declare if they have any potential conflicts of interest;
·  confirm they will not misuse any knowledge or information obtained while employed by HHL Group.
Situations that may lead to a conflict of interest include:
·  secondary employment with other organisations;
·  involvement in other businesses that work in opposition, or provide services to the organisation;
·  beneficial interests in a Trust;
·  family or close personal relationships with staff and/or clients.
Considering this, do you have any potential conflicts of interest? □ Yes □ No
If ‘yes’, please state the nature of these conflicts:
9. Referees
Please list three referees who we could contact about your suitability for the position. At least two recent work related referees, including your current or most recent manager.
Referee 1 / Referee 2 / Referee 3
Name of Referee
Company Name
Position
Relationship to applicant
Phone number
Do we have permission to contact these referees? / □ Yes □ No
Have you been employed by HHL Group or one of our divisions previously? / □ Yes □ No
If ‘yes’, please select from the following:
□ HHL Group □ Healthcare of New Zealand Limited
□ NZCare Group Limited □ Healthcare Rehabilitation Limited
□ Healthcare Mental Health Limited □ Explore Services Limited
□ Wellcare Education Limited □ Other: ______
10. Annual Practicing Certificate
Please answer this section if you are a registered nurse or allied health professional.
Do you have a current practicing certificate? / □ Yes □ No
Do you have any disciplinary, complaint or competency proceedings with the Nursing Council of New Zealand or any other investigative regulatory body? / □ Yes □ No
If yes, please give the details of the status of any investigations and/or the outcome of the proceedings and any restrictions on your practise?
11. Mandatory Training
You will be required to undertake relevant training for the role as part of your induction. This may include on-the-job training and/or attendance at appropriate courses. These will be discussed in detail if you are successful in your application.
Do you agree to attend training and (if applicable) gain relevant national qualifications? / □ Yes □ No
Do you give permission for a NZQA Record of Learning check to be completed, in order to plan the best learning pathway for you as a new employee? / □ Yes □ No
12. Availability
What kind of employment are you seeking? / □ Full time □ Part time □ Casual
Are you able to work on a rotating roster over a 7-day week, including night shifts? / □ Yes □ No
Please state the days and times you are available:
Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
AM
PM
Are you available to work during the school holidays? / □ Yes □ No
Are you restricted to working limited hours? / □ Yes □ No
If ‘yes’, please detail any restrictions below:
13. Authority and Declaration
In assessing my suitability for employment, I hereby authorise:
·  my referees to disclose personal information about me to the organisation
·  the organisation to collect this information, and to disclose it as necessary.
I have read the above Privacy Act statement, and I am aware of my rights under the Privacy Act 1993.
I undertake that all information provided by me is correct, complete and not misleading. I understand and agree that providing incorrect, misleading or incomplete information may result in my being disqualified from this application process, or dismissed if I have successfully obtained employment.
Signed: ______
Name (print): ______
Date: ______
14. Equal Employment Opportunity (EEO) Statistics
We are committed to being an equal opportunities employer and wish to monitor the effectiveness of our recruitment practices. This information is voluntary and is gathered for statistical purposes only. It will not form part of your application.
Gender: □ Male □ Female
Ethnicity: □ New Zealand Māori □ New Zealand European □ Pacific
□ Asian □ Other European □ Other ethnic origin
Disability: Do you consider yourself to have a long-term condition or health problem that has lasted, or is expected to last, for six months or more? / □ Yes □ No
How did you hear about this vacancy?
□ Newspaper □ Website □ Word of mouth
□ Seek □ Trade Me □ Recruitment Agency □ Other
If you checked Newspaper, Website or Other, please specify:

Human Resources Page 4 of 5 2.1 Recruitment

Revised Date: September 2015 Review Date: September 2017

Owner: Group GM People & Performance Version 3