To Be Completed Personally by Applicant

CONFIDENTIAL

To be completed personally by applicant

Date of Application:______

(Please Print)

PERSONAL DETAILS

Name
(in block letters) / Surname
First Names
Are you known by any other name(s)
Contact Details / Contact Address /
Home Telephone / Mobile:
Email Address
For EEO Statistics Only / Male / / Female / / Ethnicity
If your application is successful, when could you commence employment?

QUALIFICATIONS/COURSES(please attach copies)

Qualifications (School or Tertiary) / Year Attained
Courses/Workshops(Relevant to the position applied for) / Year Attained
Present or Most Recent Employer
Company
Address
Job Held
Main Duties
No hours worked per week / Dates of Service / to
Reason for leaving
For the purposes of compliance with the Privacy Act 1993, do you consent to the Waikato Kindergarten Association contacting your most recent employer for the purposes of reference checking? Yes/No
NEXT Most Recent Employer
Company
Address
Job Held
Main Duties
No hours worked per week / Dates of Service / to
Reason for leaving

EMPLOYMENT HISTORY

VERBAL REFEREES

Should you be successful in gaining an interview for this position, we will need to talk with at least one of your last two supervisors/managers to ascertain your suitability for the position. If you give permission to do so please complete their details below:
a) / Manager/Supervisor Name
Workplace
Position
Contact telephone Number / Mobile
b) / Manager/Supervisor Name
Workplace
Position
Contact telephone Number / Mobile

CONSENT

I ………………………………………… (full name) consent to the Waikato Kindergarten Association seeking verbal or written information on a confidential basis about me from my named referees. I authorise the information sought to be released by them to the Waikato Kindergarten Association for the purposes of ascertaining my suitability for the position for which I am applying. I understand that the information received by the Waikato Kindergarten Association is supplied in confidence as evaluative material and will not be disclosed to me.

Signature:………………………………………………..Date: ………………………………………..

PLEASE STATE SPECIFIC SKILLS, INTERESTS AND ABILITIES RELEVANT TO THIS POSITION:

(Refer to the Person Specification)
(Use additional pages if required)

HEALTH AND SAFETY

A staff member maybe required in their normal course of duties to lift and carry equipment and/or children. Have you had an injury or medical condition caused by gradual process, disease or infection that may be aggravated or further contributed to by the tasks of the job, or effect the safety of others? YES/NO
If YES, please detail:

ENTITLEMENT TO WORK

I am entitled under the Immigration Act 2009 to undertake the work that this application relates to. Tick the box that applies to you; and if you are successful in gaining an interview for this position you will be required to provide documentary evidence regarding your entitlement to work.
/ I am a New Zealand or Australian Citizen / / I hold a New Zealand residence permit
/ I hold a work permit with conditions permitting this employment / / I hold a visitor or student permit with conditions permitting this employment
Signature: ………………………………………………..Date: …………………………………………

DECLARATION

I ………………………………………. (full name) declare that 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 also understand that any false information given in relation to my medical history with regards to gradual process, disease or infection can result in my loss of entitlement for any compensation from ACC.

Signature: ………………………………………………………Date:……………………………………………….

WKA A.04 Version 04

May 2013Page 1 of 3