VACANCY FORM
Send by email to: recruit@epa.govt.nz
Please ensure you complete this form, answering all the questions and signing and dating it. Attach your curriculum vitae, including
details of your employment history, experience, education, and qualifications, together with a covering letter giving reasons for
applying for this vacancy.
1. Applicant’s Details
Position applied for:
Surname/Family name:
First name(s):
Postal address:
Telephone numbers:
Home:
Cellphone:
Work:
Email address:
2. Eligibility for Employment in New Zealand
To be employed in New Zealand, you must have one of the following (Please tick the box next to the status you
hold.)
New Zealand Citizenship
New Zealand Permanent Residency
A Permit and/or visa to work in New Zealand
Evidence of your entitlement to work in New Zealand will be required from both New Zealand citizens and non-New
Zealanders during the recruitment stage.
I authorise the Environmental Protection Authority to use this information for the purpose of confirming my
eligibility for employment in New Zealand.
3. Qualifications
Where a qualification is relevant to the role, we require your authorisation to confirm your academic qualification(s)
with the relevant academic provider during the recruitment stage. Please complete the table below if applicable.
Name of Qualification
Name of Academic Provider
Date Qualification Received
I authorise the Environmental Protection Authority to use this information for the purpose of confirming my
academic qualification(s) with the relevant academic provider.
4. Health
Do you have any injuries or medical conditions that could affect your ability to do this job?
Yes
No
Do you suffer from any gradual process or overuse injuries? e.g. RSI, OOS (which includes tendonitis, carpal
tunnel syndrome, tennis elbow/epicondylitis, etc).
Yes
No
If you have answered yes to either of the above, please give details:
5. Criminal Convictions
NOTE: The Environmental Protection Authority requires you to disclose all convictions unless they are covered by
the Criminal Records (Clean Slate) Act 2004.
This means you must declare all of your convictions if you have:

been convicted of an offence within the last 7 years; or

been sentenced to a custodial sentence (e.g. imprisonment, corrective training, borstal); or

been ordered by a court during a criminal case to be detained in a hospital due to your mental condition,
instead of being sentenced; or

been convicted of a “specified offence” (e.g. sexual offending against children and young people or the
mentally impaired); or

not paid in full any fine, reparation, or costs ordered by a court in a criminal case; or

been indefinitely disqualified from driving
PLEASE ANSWER THE FOLLOWING QUESTION BASED ON THE ABOVE CRITERIA
Have you been convicted of a criminal offence in New Zealand or any other country, or do you have any criminal
charges pending?
Yes
No
If “yes”, please provide full details, including date and nature of the charges, and expected hearing date if
applicable.
Do you have any fines or reparation owing?
Yes
No
If “yes”, you will be required to pay the fine and / or outstanding reparation in full prior to being confirmed into this
position.
6. Declaration
Please note that if you have given incorrect or misleading information, or have omitted any information, you may be
disqualified from appointment, or if appointed, you may be liable to be dismissed.
I declare that the statements made in this application and the accompanying CV are true and complete to the best
of my knowledge.
Signature:
Date:
7. Equal Employment Opportunity
The Environmental Protection Authority’s EEO policy strives to continually develop and improve appropriate EEO
practices that benefit everyone in our workplace. The following information is requested to assist in monitoring this
policy and is for statistical purposes only. Completing this section is voluntary. Please tick appropriate boxes.
Male
Female
Mäori
New Zealand European
Other European (please specify):
Pacific Peoples (please specify):
Asian (please specify):
Other ethnic group (please specify):
8. How did You find out about this Vacancy?
Environmental Protection Authority Website
Seek Website
Trademe Website
NZ Government Jobs Website
Newspaper (which one):
Other (please specify):