Family Planning

Family Planning

Employment Application Form

Confidential

This information is collected for the purpose of assessing your suitability for employment with Family Planning. It will remain confidential to the Human Resources Advisor and those staff directly involved in the selection process. The treatment of any information provided will comply with the Privacy Act 1993. You have a right of access to personal information about you held by Family Planning and you are also entitled to request information about you to be corrected. This information will be securely held until an appointment is made, after which it will be destroyed, unless you are appointed to a role and the information will be placed on your personal file.

Please complete this form personally, answering all questions, and sign it. You should attach the form to your covering letter and resume and send your application to the address listed in the advertisement before the closing date.

Applicant Information
First name(s): / Last name:
Current address:
E-mail address: / Home phone:
Preferred contact method: / selectCellphoneHome numberWork numberEmail / Cell phone:
Position Applied for: / Date available:
Have you been previously employed by Family Planning / YES / NO
If yes, where, when and in what position?
Have you ever been dismissed or asked to resign from a job? / YES / NO
If yes, please give details?
Do you have a current full NZ driving licence? / YES / NO
Do you have any endorsements on your driving licence? / YES / NO
Do you have access to a vehicle for work purposes if required? / YES / NO
Are you legally entitled to work and live in New Zealand? / YES / NO
If you are legally entitled to work because you have a work permit, when will this expire?
authority to practice (select box if N/A)
Do you have a current New Zealand Annual Practising Certificate/Registration?
Please attach a copy. If appointed please produce the originals of documentation for sighting. / YES / NO
professional discipline (select box if N/A)
Have you been subject to a professional disciplinary inquiry in NZ or any other country, or have knowledge of an event that might give rise to a disciplinary inquiry? / YES / NO
If yes, please give details?
convictions and proceedings
Have you ever been convicted of a criminal offence or are you presently awaiting court proceedings for any criminal offence outside of the criteria in Section 7of the Criminals Records (Clean Slate) Act 2004? / YES / NO
If yes, please give details?
Would you be willing to sign Family Planning’s Consent to Disclosure of Information form
which provides Family Planning with permission to undertake Police vetting? / YES / NO
health
Do you have any injuries, medical conditions, or other personal circumstances that may be aggravated by or affect your ability to effectively carry out the tasks and responsibilities described in the position description?
YES NO If yes, please provide details:
Do you suffer from anything that may affect your ability to perform the role for which you have applied (for example OOS, back injury, stress related illness)?
YES NO If yes, please provide details:
Please note: The Human Rights Act 1993 defines disability as: physical disability or impairment; physical illness; psychiatric illness; intellectual or psychological disability or impairment; the presence in the body of organisms capable of causing illness; any other loss or abnormality of a body or mind function; and reliance on a guide dog.
Referees
Please provide names of two referees whose consent has been obtained and who may be contacted for a confidential reference if you are short listed. (It is preferred, at least one should be able to give work-related information and should have supervised or been senior to you in your current or most recent employment.)
Name / Position / Phone
Company / Email / Cell
Referees relationship to applicant:
Name / Position / Phone
Company / Email / Cell
Referees relationship to applicant:

Declaration

·  I declare that to the best of my knowledge the answers in this application are correct and I understand that if any false or misleading information is given, or any material fact suppressed, I will not be accepted, or if I am employed, my employment may be terminated summarily for serious misconduct.

·  I agree that I will inform Family Planning if there are any changes to the information that I have provided, whether during the recruitment process or as an employee should my application be successful.

·  I give my permission for referees to be contacted if I am short listed for this position.

·  I understand that all members of staff are required to comply with Family Planning policies and procedures, in addition to legislation and regulation governing organisational function and individual practice.

·  I understand that ongoing education and quality improvement are integral parts of employment and I will be expected to contribute to and participate in appropriate programmes.

Signed: ______Date:

(If sent by email, and you are interviewed, you will be asked to sign this form at the interview.)

Applicant EEO Statistics Form

Confidential

Family Planning operates an Equal Employment Opportunities policy where an equal employment opportunity is defined as a situation in which a person’s race, sex, sexual orientation, general relationship status, physical disability, age or any other personal characteristic irrelevant to the effective performance of a job, does not enhance or hinder that person’s chance of winning the job.

This information is gathered to assist in monitoring Family Planning’s Equal Employment Opportunities Policy and is collected for statistical purposes only.

Please forward this form with your application. It will be separated from your application as soon as it arrives and forwarded to the Human Resources Advisor. The information provided will not be considered as part of the selection process.

Position Information
Position applied for:
Area/location of position:
Application date
Is the position full time (40 hours per week) / Is the position part time
How did you find out about this vacancy? / selectSeek websiteNewspaperNZ DoctorFamily Planning websiteFacebookFamily Planning E-NewsletterStaff member referralOther
other, please state
Applicant Information
Gender? e.g. female
Please select your age grouping
Under 20 years 20 – 29 years 30 – 39 years 40 – 49 years
50 – 59 years 60 years and over
To which ethnic group or groups do you belong to? (tick the box or boxes that apply to you):
Māori / Please give tribal affiliation:
Niuean / Please specify
Tongan / Please specify
Cook Island Māori
Samoan
Indian
Chinese
NZ European
Other ethnic group, please state
If not born in New Zealand, state country of origin
Number of years in New Zealand