NGĀTūRANGA MAHI / Position Applied for:
Vacancy Number / Where did you see this position advertised?
PERSONAL DETAILS
TAHA TANGATA / Last name: / First Name(s):
Postal Address:
Email: / Phone (am):
Mobile: / Phone (pm):
REFEREES
KAITAUTOKO / Please provide details of two people who may be approached for a confidential statement about your suitability for this position (referees should be able to provide work related information and one should be your current manager orsomeone who has directly supervised you).
Name: / Name:
Position: / Position:
Company: / Company:
Email: / Email:
Phone: / Phone:
RESIDENCESTATUS
MANANOHONGA / Are you a New Zealand citizen? Yes No
If no, are you legally entitled to work in New Zealand? Yes No
Please attach a copy of your resident permit / work visa Attached
QUALIFICATIONS
TOHUMĀTAURANGA / Qualification:
Major Subject:
Awarded By: / Year:
Qualification:
Major Subject:
Awarded By: / Year:
PRACTISINGCERTIFICATES / REGISTRATIONS
RĒHITATANGA / Details:
Number: / Expiry Date
Details:
Number : / Expiry Date
Details:
Number: / Expiry Date
EMPLOYMENT HISTORY
ŌU TŪRANGA MAHI / Name of Employer:
Position Held:
Details of role and responsibilities:
Period of Employment: / From: Click here to enter a date. / To: Click here to enter a date.
Name of Employer:
Position Held:
Details of role and responsibilities:
Period of Employment: / From: Click here to enter a date. / To: Click here to enter a date.
Name of Employer:
Position Held:
Details of role and responsibilities:
Period of Employment: / From: Click here to enter a date. / To: Click here to enter a date.
Name of Employer:
Position Held:
Details of role and responsibilities:
Period of Employment: / From: Click here to enter a date. / To: Click here to enter a date.
EEO / WITT is an Equal Opportunity Employer. The following information is valuable in assisting and monitoring our equal employment opportunities policy. It is gathered for statistical purposes only and is optional for completion. It will not be used in making a selection decision.
Ethnic Origin: Which ethnic group do you identify with?
New Zealand European
Māori (please specify iwi affiliations)
European Pacific Peoples (please specify)
Middle Eastern/Latin American/African (please specify)
Asian (please specify) Other Ethnicity (please specify)______
Gender: Male Female Date of Birth: ____/____/____
OTHER
ĒTEHI ATU / Do you have a current drivers licence? Class(es)______Yes No
Have you previously been/are you currently an employee of WITT? Yes No
Period employed: from ____/____/____ to ____/____/____
Position held: ______
Do you have a relative who is currently employed by WITT? Yes No
If you are shortlisted, do you wish to bring Whānau/ support with you? Yes No
HEALTH & SAFETY
HAUORA ĀRAI AITUĀ / Is there anything that might prevent you from performing the full range of tasks involved in this position, including the effects from any previous or current injuries or health conditions?
Yes No
If you have answered “yes” please provide details:
______
______
______
Please describe any support that would be needed to ensure your health and safety, which may include technical aids, equipment or adaptations to the work environment.
______
______
______
CRIMINAL OFFENCES
NGĀ MAHI TAKAHI I TE TURE / WITT requires you to disclose all convictions unless they are covered by the Criminal Records (Clean Slate Act) 2004. If you would like more information on what disclosure is required, please contact the Human Resources Department at WITT.
You must declare all of your convictions if you have:
- been convicted of an offence within the last 7 years; OR
- been sentenced to a custodial sentence (e.g. imprisonment, corrective training, borstal); OR
- been ordered by a Court during a criminal case to be detained in a hospital due to your mental condition, instead of being sentenced; OR
- been convicted of a “special offence” (e.g. sexual offending against children and young people or the mentally impaired); OR
- not paid in full any fine, reparation or costs ordered by the Court in a criminal case; OR
- been indefinitely disqualified from driving under Section 65 Land Transport Act 1998 or earlier equivalent provision.
No, none of the above criteria applies to me or I have no convictions
Yes, at least one of the criteria applies and I will disclose my criminal convictions below.
______
______
______
______
______
______
The non-declaration of an offence that you are required to disclose will be seen as a misrepresentation of a criminal record and treated accordingly.
DECLARATION
KUPU WHAKAHAU / I declare that the information I have supplied in this application is true and correct. Providing false or incomplete information would be grounds for non-appointment or could lead to grounds for dismissal in the event that your application is successful.
I authorise WITT to contact the referees I have named to obtain a reference and to discuss my application with them.
Signed:______Date:______
By typing your name above you are electronically signing this form.
If your application is successful, this information will become part of your personnel record. You are entitled to access this information upon request.
If your application is unsuccessful, this information will be stored in line with the Privacy Act 1993.
Please keep a copy of your application for employment for your record.
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