Candidate Authority and Application Form

Full name

Date of Birth

Phone number

Contact address

Email address

Tertiary Qualification(s)

Professional membership details and number

REFEREE DETAILS

Please provide details of at least two relevant referees

REFEREE ONE:

Name

Title

Organisation

Address

Phone

Relationship to you

Period of employment

REFEREE TWO:

Name

Title

Organisation

Address

Phone

Relationship to you

Period of employment

REFEREE THREE:

Name

Title

Organisation

Address

Phone

Relationship to you

Period of employment

Please confirm details and/or answer the following questions

1. Are you legally entitled to work in New Zealand?

2. Do you have any medical conditions or substance dependency which may affect your ability to effectively carry out the functions and responsibilities of employment, or which may be aggravated or further contributed to by the function and responsibilitie for employment.

If you answered YES to question 2 please specify the medical conditions or substance dependency:

3. To assist a potential organisation assess your condition and the possible effects of the position on your health, are you prepared to undergo a medical examination by a doctor nominated by your potential employer at his/her/its expense?

4. Are there any special services or facilities which an organisation could provide to enable you to carry out the work duties?

If YES to number 4, please detail:

5. Do you currently have or have you previously had any symptoms of back injury or occupational overuse syndrome (OOS) when performing any activities that may have an impact on your ability to perform the position/s for which you are applying?

If YES to number 5, please detail:

6. Is there anything your employer should know that may affect your ability to carry out any work duties?

If YES to number 6, please detail:

7. Have you had any criminal convictions involving fraud, dishonesty, acts of assault or violence?

a) Are you awaiting the hearing of charges relating to any criminal offence?

b) Have you been subject to an investigation for dishonesty or violence?

c) Have you been dismissed from any previous employment?

If you have answered YES to any one or more of questions in question 7, please specify details (please note that under the Criminal Records (Clean Slate) Act 2003, you are not required to disclose certain offences.

8. Have you had any employment related disputes that have necessitated informal or formal mediation, dispute resolution or involvement by the Employment Authority/Tribunal or Court – either past, current or pending?

If YES to number 8, please detail:

9. Are you subject to a restraint of trade pursuant to your current or any former employment agreement?

If YES to number 9, please detail:

10. Do you have any potential conflicts of interest in respect of the role under consideration?

If YES please specify details of the potential conflict.

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Candidate Authority and Application Form

REFEREE DETAILS

Please provide details of at least two relevant referees

REFEREE ONE:

REFEREE TWO:

REFEREE THREE:

Please confirm details and/or answer the following questions

View Declaration and Authorisation

Business Growth Manager Business Development, Partnerships, Community Good

Production Planner Maximise Potential!

Chief Commercial Officer Enable

Unit Head ChristchurchNZ