Application for Employment s98
CONFIDENTIAL
Application for Employment
COLLECTING AND HOLDING PERSONAL INFORMATION: / The information you provide on this application for employment will be collected and held by the Health and Disability Commissioner.PURPOSE: / This information is collected for the purpose of assessing your suitability for employment with the Health and Disability Commissioner which may include subsequent changes in employment within the office of the Health and Disability Commissioner.
YOUR ACCESS TO THIS INFORMATION: / You have a right of access to personal information and to seek any correction you think necessary to ensure accuracy.
POSITION APPLIED FOR: / Employment with the Health and Disability Commissioner for the position of
………………………………………………………………………………………
Note: In order for us to consider your application you should provide complete information in answer to each question unless otherwise advised, regardless of whether you consider it relevant to the position applied for. Information given in Sections 1 – 3 can be repeated and expanded in your CV which you are encouraged to attach to this application.
SECTION 1 - PERSONAL INFORMATION (Please print)
First name(s) / Last name / If you are known by any other names please record them here:
Address:
Telephone: / Residential: / Business:
Mobile: / Email:
SECTION 2 - EDUCATION (INCLUDING UNIVERSITY, FURTHER EDUCATION ETC)
Name of School/College/Polytechnic/University / From / To / Qualifications/Standard of Achievement/ Accomplishments
SKILLS AND EXPERIENCE (regardless of formal qualifications)
SECTION 3 - EMPLOYMENT HISTORY (start with the most recent position)
Name of Employer / Length of Service
From To / Position Held / Nature of Work / Reason for Leaving
Have you previously been employed by the Health and Disability Commissioner? Yes No
Do you agree to enquiries being made as to the accuracy of information contained in this application form or any other matter relating to your suitability for employment?
Present Employer: Yes No / Past Employer: Yes No / Other Person: Yes No
REFEREES: Please give details of at least two work-related referees who you authorise us to contact.
Name: / Email Address: / Phone No. / Occupation/Position Held:
SECTION 4 - GENERAL
Do you intend to engage in other paid work whilst employed in this position?
If yes give brief details: / YES ¨ NO ¨
Have you been charged with or convicted of a criminal offence in the last 10 years (other than a conviction that you are lawfully entitled to withhold under the Criminal Records (Clean Slate) Act 2004)?
If yes give brief details: / YES ¨ NO ¨
Are you aware of any possible conflict of interest that may arise, if you were to be offered, and accept, employment with HDC?
If yes give brief details: / YES ¨ NO ¨
If your application is accepted when you could you start employment?
What are your salary expectations for this position?
Are you legally entitled to work in New Zealand? / YES ¨ NO ¨
Where did you see the role advertised? / HDC Website ¨
Seek ¨
Government Jobs Online ¨
Other (please state): ………………………………………………………
SECTION 5 - MEDICAL
Do you have any health related condition which may affect your ability to effectively carry out the functions and responsibilities of the position applied for? If so, please give details:
SECTION 6 - DECLARATION
I, …………………………………………………………………...... … (full name) declare that to the best of my knowledge, the answers to the questions in this application are correct. I understand that if any false or misleading information is given, or any material fact suppressed, I may not be accepted, or if I am employed, I may be dismissed.
Date: / Signature:
SECTION 7 - ADDITIONAL INFORMATION
Do you have any additional information which you would consider may assist your application. For example, achievements, interests, aspirations etc. If so, please list below or attach any additional information to this application form.
Health and Disability Commissioner
PO Box 1791, Auckland, NZ. Phone 0800 11 22 33 / 09 373 1060 Fax 09 373 1061