PERSONAL INFORMATION PLEASE PRINT OR TYPE. ANSWER EACH SECTION IN ITS ENTIRETY

Mr/Mrs/Miss/Ms:

Surname: Former Names:

First Name:

Address:

Telephone No (res) Cell Phone:

Email address: Skype address:

Marital Status: Name of spouse/partner:

Dependants:

Place of Birth: Are you a NZ Citizen/Perm Resident:

Driver’s Licence No: Passport No:

PLEASE INDICATE THE SPECIFIC ROLE YOU HAVE APPLIED TO OR THE TYPE OF ROLE YOU ARE SEEKING

Clinical areas of expertise (if relevant)

A&E (ED) / General Surgical / Midwifery / Theatre / OR
Haematology / General Medical / Obstetrics / Recovery
Cardio/Cardiac / Plastics / Paediatrics / Anaesthetics
Ear Nose Throat(ENT) / CCU/ICU / Orthopaedics / Neurology
Ophthalmology / PICU / NICU / Oncology / Mental Health
Eldercare (Geriatrics) / Palliative Care / Renal / Clinic/Practice
Dementia / Community / Clinical Nurse Tutor / Occupational Health

Please circle which best applies to your employment requirements:

Full time

Part time

Contract (indicate preferred timeframes for contract work)…………………………………………………………………………….

TERITARY EDUCATION

Give details of qualifications.

University/HospitalQualificationsDates Received

Post Graduate and/or training courses completedDate / year attended

Career Objective (describe briefly, your goals and aspirations in the healthcare profession)

Hobbies / Interests / Special Achievements

PROFESSIONAL REGISTRATION REQUIREMENTS (if relevant e.g. for Nurses):

Do you have Professional Registration □ yes □ no Which country ______

Are you registered in New Zealand □ yes □ no Practicing Cert No.______

Do you have the right to work in NZ □ yes □ no Visa TYPE / No ______

Do you have any mental or physical conditions that could affect your nursing practice Yes □No □

Legal Information

Have you ever been convicted of a criminal offence in this country or any other or have pending court cases/hearing or concerns of this nature or will there be any comments / notes on a police check about you? (if yes please give some detail below, as a criminal check will be undertaken; Yes □ No □

Have you been or are you currently being investigated for a crime or a professional disciplinary action in any country?

(if yes please provide details below where possible)Yes □No □

If relevant - Have you ever been declined professional registrationin this country or any other?

Yes □No □

EMPLOYMENT HISTORYCommence with the name and address of your most recent employer first (show months and years).

Employer Name:

Type of Employer

Position Held:Date Commenced:To:

Manager (role reported to):Hour Rate/Salary:

Key components of the role (clinical, leadership, audit, staffing etc)

Reason for Leaving:

Employer Name:

Type of Employer (Hospital / Clinic / Specialist / Community/ TrainingHospital / Commercial) No. of Wards/Beds

Position Held:Date Commenced:To:

Manager (role reported to):Hour Rate/Salary:

Key components of the role (clinical, leadership, audit, staffing etc)

Reason for Leaving:

Employer Name:

Type of Employer (Hospital / Clinic / Specialist / Community/ TrainingHospital / Commercial) No. of Wards/Beds

Position Held:Date Commenced:To:

Manager (role reported to):Hour Rate/Salary:

Key components of the role (clinical, leadership, audit, staffing etc)

Reason for Leaving:

If you haven’t already - Please attach a copy of your CV with this application, including list of all in-service education AND professional development programs attended

ANY OTHER INFORMATION TO SUPPORT YOUR APPLICATION

Please make notes of any further credentials or attributes you would like to highlight as part of your application below:

______

REFEREES

Please provide the names 3 professional people who can attest to your character and abilities

Referee Name / Title / Company / City / Phone/email

CANDIDATE DECLARATION

The information you provide on this Employment Application Form is being collected and will be held byMedcall for the purpose of assessing your suitability for employment/placement with Medcall or Medcallclients. This information is also being collected for the purpose of complying with employment related legislationsuch as the Accident Compensation Corporation (ACC), and Health & Safety. Failure to complete all sections truthfully will render this application invalid and, should you havebeen successful in your application, may be grounds for dismissal. This information shall be held in theorganisation’s personnel file and only appropriate personnel shall have access to it and that may include3rd party service providers (e.g. IT or payroll providers) contracted with Medcall along with clients/otherswho may require the information as part of their

consideration for your employment. You have the right to view your personal information and may request correction if necessary and Medcall’s privacy policyis available to you.

Ideclare that to the best of my knowledge the answers given in this application are complete and correct, and that the information provided in my curriculum vitae is correct. I also declare that all documents given as part of this application are true, accurate and genuine. I understand that provision of incorrect or misleading information may result in my summary dismissal. I understand that if any false information is given or any material fact suppressed, I may be disqualified from consideration or, if appointed, I may be dismissed. I have read and understood and agree to the provisions of this application form. If I am employed before the results of my police check are supplied to Medcall I understand that my employment may be terminated if the police check reveals information that Medcall considers makes me unsuitable for the job or which contradicts statements I have made on my application. I understand that if I have supplied any false or deliberately misleading information, or if I have suppressed any material information, I may not be offered the position applied for, or if employed, my employment may be terminated.

I understand my contact details will be added to a subscription list for occasional email newsletters, jobs, competitions or market information/blogs, but that by checking this box, I will not be included on that list and I can unsubscribe at any time

Signature______Date ______

INTERVIEW COMPLETED BY:______DATE:______