Employment Application Form
APPLICATION FOR EMPLOYMENT
POSITION APPLIED FOR:
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.)
(Start with your most recent employment and work backwards)
(Please provide a copy of your academic record with your CV)
If yes, please list:
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.
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.
Any offer of employment with Hospice is made subject to the satisfactory completion of a pre‑employment medical examination.
If yes, please detail:
Hibiscus Hospice offers vaccinations to protect staff against TB, Hepatitis B and influenza, and screens for MRSA.
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.
If YES please complete the Police Check Form attached. (attach form)
If offered this position, when are you available to start? ______________________________________
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.
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.