Attached Is an Application for Employment Form Which You Are Requested to Complete Personally

APPLICATION FORM

Attached is an Application for Employment form which you are requested to complete personally.

The application form is a source of information, which will be used by the Company to assist it in considering your suitability for the position for which you are applying. If successful, such information shall form part of the Company’s personnel records. Failure to supply the information requested would prejudice the Company’s ability to assess your suitability for the position.

Any offer of employment is made subject to your completing the Company’s pre-employment health assessment to its satisfaction.

You are entitled to access this information upon request to the Company’s Privacy Officer.

Their location is:166 Karetoto Road

SH1 Wairakei

Taupo

Or

PO Box 341

Taupo 3351

Provided that information relating to unsuccessful applicants shall be retained by the Company for a period of 12 months. The above information is provided in accordance with the Privacy Act 1993.

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CONFIDENTIALTo be completed personally by Applicant
Date of Application:
Application for Employment
Note:The completion of this form does not indicate that there is any obligation on the company to engage the applicant.
Purpose:This information is collected for the purpose of assessing your suitability for employment at Century Drilling & Energy Services (NZ) Ltd which may include subsequent changes in employment with the company.
MB Century use only
Review Date / Name / Signature / Comments
PLEASE PRINT
Position Applied For:
Your Name
In block letters / How do you like to be addressed:
Family Name:
Given Names (underline name used):
Are you known by any other name(s)?
Your Contact Address and Telephone Numbers / Contact Address:
Home Phone No: Other No. (If any):
Email Address:
Do you consent to the Company using this email address to email you documents: Yes/No
Have you reached the current school leaving age?Yes/No
Legal Work Status / Are you legally entitled to work in New Zealand?
As:A New Zealand Citizen?Yes/No
A permanent resident?Yes/No
*A holder of a current work visa?Yes/No
*If Yes please provide a copy of your current work Visa
Education
Including university, further education, etc where applicable / Name of secondary school(s) attended
Education (continued) / Qualifications
( NCEA, School Certificate, University Entrance, Bursary) – Subjects
Please provide certified copy of Tertiary and professional qualifications / Other Tertiary & Professional qualificationsYes/No
PLEASE ATTACH CERTIFIED COPIES
Languages / Can you hold an every day conversation in any language other than English? If yes, what languages?
------
Apprenticeship
For trades positions only / Do you have your apprenticeship papers?Yes/No
PLEASE ATTACH CERTIFIED COPIES.
In what trade were you apprenticed?
What was the name and address of the employer?
Name:
Address:
What trade qualifications do you hold (i.e. Trade Cert, Advanced Trade Cert., etc)?
Driving Licence/s / Do you have a current drivers licence?Yes/No
If yes, what class/es?
Drivers Licence No.:
Drivers Licence Version No.:
Do you have any demerit points or special conditions?Yes/No
Do you have any cases pending?Yes/No
If yes, please detail
For the purposes of compliance with the Privacy Act 1993 do you consent to the Land Transport NZ (LSTA) releasing to the Company information regarding your Driver Licence Yes/No
Curriculum Vitae (CV) / PLEASE PROVIDE A CURRENT C.V. Attached Yes/No
Qualifications / DO YOU HAVE A NZQA NATIONAL STUDENT NUMBER (NSN)?
NSN Number:
PLEASE PROVIDE A CURRENT PRINTOUT OF NZQA “RECORD OF ACHEIVEMENT” Attached Yes/No
DO YOU HAVE ANY OF THE FOLLOWING QUALIFICATIONS?
PLEASE ATTACH COPIES.
Forklift (OSH)Expiry Date: ____/____/____
First Aid Cert (US6400,6401,6402) Expiry Date: ____/____/____Expiry Date: ____/____/____
Basic Life SupportExpiry Date: ____/____/____
Basic First AidExpiry Date: ____/____/____
Fire FightingExpiry Date: ____/____/____
Confined SpaceExpiry Date: ____/____/____
Working at Heights/Fall ArrestExpiry Date: ____/____/____
Breathing Apparatus (CABA)Expiry Date: ____/____/____
WELDING TICKETS (PLEASE SPECIFY)):
DO YOU HAVE ANY OTHER QUALIFIACTIONS/CERTIFICATES LICENCES/ OR ATTENDED ANY COURSES?
PROVIDE DETAILS INCLUDING DATE OF ATTAINMENT & EXPIRY DATE WHERE APPLICABLE & ATTACH COPIES.
PLEASE DESCRIBE THE SKILLS YOU HOLD WHICH ARE RELEVANT TO THE POSITION APPLIED FOR
Medical History / Please provide details of any medical conditions or previous injuries that will affect your ability to carry out the position work requirements.
Employment History / Present or Most Recent Employer:
Company:
Address:
Job Held:
Main Duties:
No of hours worked per week: ……… Length of Service: …………..Length of Service:
Reason for Leaving:
For the purposes of compliance with the Privacy Act 1993 do you consent to the Company contacting your present employer for the purposes of reference checking at the point that a job offer is
made to you?Yes/No

Next Most Recent Employer

Company:
Address:
Job Held:
Main Duties:
No of hours worked per week: Length of Service:
Reason for Leaving:
Next Most Recent Employer
Company:
Address:
Job Held:
Main Duties:
No of hours worked per week: Length of Service:

Reason for Leaving:

Give details of any other job which may be relevant:
Have you ever worked for this Company or an associated
Company before?Yes/No
If yes, where and when:
Do you have secondary employment? Yes/No
If yes, please detail:
Referees / Give name, address and telephone numbers of at least three referees.
Name:
Position:
Address:
Phone Number:
Name:
Position:
Address:
Phone Number:
Name:
Position:
Address:
Phone Number:

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General / Are you prepared to work shifts if required to do so?Yes/No
Have you worked shifts before?Yes/No
Are you prepared to work overtime, including weekends if
required?Yes/No
Have you been convicted of a criminal offence?Yes/No
If yes, please detail:
Have you been the subject of a Diversion ordered by the
Courts?Yes/No
Are you awaiting the hearing of charges in a civil or criminal
court of law?Yes/No
Are you prepared to handle all products, materials, or
equipment used in the industry?Yes/No
Do you have a spouse, partner, relative or household-member
working here or elsewhere in the industry?Yes/No
If yes, who?
Where?
What transport arrangements do you have to attend your place of employment?
Can you think of anything that may affect your regular attendance at work?Yes/No
If yes, please detail:
What are your interests/hobbies/sports/clubs or community activities?
If your application is successful when could you commence employment?
Medical / If you are offered employment the offer is made subject to your obtaining a full medical clearance following the completion of our pre-employment medical.
Do you agree to undergo a medical examination?Yes/No
Do you consent to any biological monitoring if applicable to
the Job? (Refer HASE Act)Yes/No
Have you had an injury or medical condition caused by gradual,
disease or infection for example hearing loss, sensitivity to
chemicals, repetitive strain injuries that may be aggravated or
further contributed to by the tasks of this job?Yes/No
If yes, please detail:
Do you consent to the Company retaining the information contained in this application form for the purposes of considering your suitability for any other position which may arise with this Company in the future? Yes/No
Declaration / I, (full name) declare that to the best of my knowledge the information provided in this application and in any resume enclosed is accurate and I understand that if any false or misleading information is given, or any material fact suppressed, I will not be employed, or if I am employed, my employment will be terminated. I further understand that any offer of employment if made is conditional on my obtaining a full medical clearance through the Company’s pre-employment medical.
Signed: Date:

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EQUAL EMPLOYMENT OPPORTUNITIES

Questionnaire

The Company has an Equal Employment Opportunity (EEO) Policy and is keen to develop appropriate equal opportunities practices that benefit everyone in the work place.

To do this we need to collect statistical information to measure progress towards achieving our EEO goals, in this instance to assess who the Company is attracting, as applicants for positions.

The completion of this form is on a voluntary basis, and if you have any objection to providing this information, there is no compulsion on you to comply with this request.

1.Position applied for______

2.Date of Birth______

3.Gender______

4.What is your present

marital status?______

5.What ethnic group

do you belong to?______

6.Describe any disability

or impairment that

you might have.______

7. (a)How did you find out

about this position?______

(b)Publication name______

(c)Other Source______

In terms of the Privacy Act 1993 this information will only be used for the purposes stated.

Please return this form with your application.

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