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Employment Application Form

APPLICATION FOR EMPLOYMENT

 

 

POSITION APPLIED FOR:

 

  • Please complete this Application for Employment Form as thoroughly as possible in your own handwriting.

  • Information provided in this Application for Employment Form will be used in the selection process only and will be kept secure and in accordance with the Privacy Act 1993.

  • The completion of this Application for Employment Form does not indicate any obligation to employ the applicant.

  • It is Hibiscus Hospice’s policy not to offer a position to any applicant without this form being completed and signed.

  • Please attach your CV in support of your application.

     

PERSONAL DETAILS

 

Family Name:

 

Given Names:

 

Preferred Name:

 

Address:

 

 

 

 

 

Day Phone No:

 

 

Are you legally able to work in New Zealand?

(Note: You may be required to produce evidence to this effect if you are offered a position.)

 

Yes

 

No

 

 

 

 

PAST EMPLOYMENT

(Start with your most recent employment and work backwards)

 

Date From

To

Employer

Position

Reason for Leaving

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUALIFICATIONS/CURRENT STUDIES

(Please provide a copy of your academic record with your CV)

 

Degree/Qualification

Date Obtained (Year)

Name of Institution

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROFESSIONAL ASSOCIATIONS

 

Are you a member of any professional associations?

Yes

 

No

 

 

If yes, please list:

 

 

 

 

DRIVERS LICENCE

 

This position may require you to drive a Hibiscus Hospice vehicle. Hospice’s insurance policy requires that we know whether you have a current licence and any convictions or pending convictions you may have in respect of your driving.

 

 

Licence No:

 

Classes:

 

Expiry Date:

 

Demerit Points:

 

 

 

Has your licence ever been cancelled?

Yes

 

No

 

 

Do you have any cases pending which could affect your licence?

Yes

 

No

 

 

If you are required to drive a Hospice vehicle, do you agree to your

name being registered with the LTSA’s Driver Check?

Yes

 

No

 

 

 

OVERTIME AND ROSTERED WORK

 

It is a condition of employment that all employees may be required to work overtime and some positions are required to work to rosters.

 

Are you prepared to work Saturday, Sundays and evening if rostered

to do so?

Yes

 

No

 

 

Are you prepared to work overtime?

Yes

 

No

 

 

 

 

HEALTH

 

Any offer of employment with Hospice is made subject to the satisfactory completion of a preemployment medical examination.

 

Do you agree to undergo a medical examination?

Yes

 

No

 

 

Do you have a medical condition or injury caused by gradual process,

disease or infection e.g. hearing loss, sensitivity to chemicals, occupational

overuse syndrome, stress, that may be aggravated or further contributed

to by the tasks of this job?

Yes

 

No

 

 

If yes, please detail:

 

 

 

 

Hibiscus Hospice offers vaccinations to protect staff against TB, Hepatitis B and influenza, and screens for MRSA.

 

Do you agree to participate in any health programme?

Yes

 

No

 

 

If no, do you agree to sign a waiver absolving Hospice from

responsibility should you subsequently become ill from any of the

illnesses in the programme?

Yes

 

No

 

 

 

You are prohibited from being impaired by drugs and/or alcohol while at work and/or driving a Hospice vehicle. Hospice will undertake drug and alcohol testing when appropriate (see Hospice’s Drug and Alcohol Policy- Health and Safety Manual ). Refusal to consent to a drug or alcohol test will be investigated. A breach of the Drug and Alcohol Policy may result in disciplinary action up to and including summary dismissal.

 

CONVICTIONS

 

Have you had any court convictions in the last 10 years?

Yes

 

No

 

 

Are you currently awaiting the hearing of any charge?

Yes

 

No

 

 

The position you have applied for is subject to a police check.

Do you agree to your details being submitted to the police?

Yes

 

No

 

 

If YES please complete the Police Check Form attached. (attach form)

 

 

 

 

 

If offered this position, when are you available to start? ______________________________________

 

 

 

References

I agree that Hibiscus Hospice may seek verbal or written information about me on a confidential basis from representatives of my previous employers and/or referees. I authorise the information sought to be released by them to Hospice for the purpose of determining my suitability for the position for which I am applying. I understand that the information received by Hospice is supplied in confidence as evaluative material and will not be disclosed to me.

 

 

___________________________________________ ___________________________________

Signature Date

 

May we contact your present employer for a reference

Yes

 

No

 

 

Declaration

To the best of my knowledge, the information provided by me in this Pre-Employment Screening Form and in my CV is true and correct. In the event my application for employment with Hibiscus Hospice is successful, this information will form part of my employment agreement. I understand that if I am appointed and Hibiscus Hospice discovers a misrepresentation or omission of information in my Pre-Employment Screening Form, CV or associated comments I may make, this will be grounds for instant dismissal. I also understand that any false information given in relation to my medical history may result in my loss of entitlement to any compensation from ACC. I agree to comply with the terms of Hibiscus Hospice’s rules, policies and procedures, which may be changed by Hibiscus Hospice from time to time.

 

I understand it will be a condition of employment that I sign a confidentiality agreement agreeing to protect confidential information pertaining to Hibiscus Hospice and to its suppliers, staff, patients and patients’ families.

 

The position I have applied for is subject to a police check, I agree that the duties I may be asked to undertake may be restricted until the results of the police check are known. I understand that my employment will be terminated in the event the result of the police check is unsatisfactory.

 

I understand it will be a condition of my employment with Hibiscus Hospice that I do not engage in any business or undertake any other employment that is, or is perceived to be, in direct competition with Hibiscus Hospice at any time.

 

 

 

 

___________________________________________ ___________________________________

Signature Date

 

 

 

TITLE: Application for Employment Form

DATE OF ISSUE: February 2011
DATE REVIEWED: February 2013
ISSUE NO: 3
AUTHORISED BY: CEO
Signature: Winsome R Stretch