EMPLOYMENT APPLICATION
CONFIDENTIAL: This information is collected solely for assessing your suitability for employment.
You must complete the form personally, answer all questions and sign the declaration. The completion
of this form does not imply any obligation on the Employer to engage you in any form of employment.
PERSONAL DETAILS:
Position Applying For:
Name:
Date of Birth:
(optional)
Contact address:
Contact telephone numbers:
Home:
Mobile:
Email address:
Next of Kin and relationship:
Contact address:
Contact telephone numbers:
Home:
Mobile:
EDUCATION AND TRAINING:
What is your highest formal qualification? (e.g. Sixth Form Certificate)
List any other qualifications you have achieved, and any relevant training you have undertaken:
WORK SKILLS:
Outline the relevant skills that you consider make you suitable for the position:
EMPLOYMENT HISTORY:
Unless you are a new school leaver, give details of your three most recent positions:
POSITION ONE:
Employer:
Position:
Main duties:
Dates employed: From ____________ to ____________.
Reason you left this job:
POSITION TWO:
Employer:
Position:
Main duties:
Dates employed: From ____________ to ____________.
Reason you left this job:
POSITION THREE:
Employer:
Position:
Main duties:
Dates employed: From ____________ to ____________.
Reason you left this job:
REFEREES:
Name:
Phone number:
Nature of relationship:
Name:
Phone number:
Nature of relationship:
CONFIDENTIAL: In providing references I consent to the above named employer seeking verbal or written information on a
confidential basis about me from my previous employers and/or referees. I authorise the information sought to be released by them
to the above named employer for the purpose of ascertaining my suitability for this position.
FARM\STAFF\RECRUITMENT\ApplicationForm.docx
MEDICAL HISTORY:
Given the physical nature of the work offered, we need the following information to assess your suitability
and also to be aware of any First Aid needs should you be involved in an accident at work.
Have you had or do you suffer from, any of the following conditions, which the tasks of this job may
aggravate or contribute to?
Comments:
*Allergies / reactions
Yes
No
____________________________
*Asthma
Yes
No
____________________________
*Back injury
Yes
No
____________________________
*Blackouts or seizures
Yes
No
____________________________
*Bronchitis
Yes
No
____________________________
*Colour Blindness
Yes
No
____________________________
*Dermatitis or Eczema
Yes
No
____________________________
*Eyesight
Yes
No
____________________________
*Phobia’s
Yes
No
____________________________
*Diabetes
Yes
No
____________________________
*Epilepsy
Yes
No
____________________________
*Hearing Impairment
Yes
No
____________________________
*Hernia
Yes
No
____________________________
*High blood pressure
Yes
No
____________________________
*Cardiac Problems
Yes
No
____________________________
*Mental health
Yes
No
____________________________
*Recurring injuries
Yes
No
____________________________
*Occupational Overuse (OOS) Yes
No
____________________________
*Other_________________________________________________________________
Are you currently taking any prescription drugs or medication? (i.e. Ventolin pain killers etc) Yes No
If so; what type and what for? _________________________________
_____________________________ _______________________________________________
List any activities / jobs you can’t do because of health or other reasons i.e. spraying, use chemicals,
drive a vehicle: _____________________________________________________
_____________________________________________________________________________
Do you have any family commitments / needs which require any special allowances; that need to be
catered for? _________________________________________ ______________________________
___________________________________________________________________________________
I agree to attend a medical practitioner when requested by the employer.
Yes
No
KIWISAVER:
If eligible, you will be automatically enrolled into the Government’s KiwiSaver scheme. Do you wish to opt
out?
Yes
No
FARM\STAFF\RECRUITMENT\ApplicationForm.docx
LEGAL ISSUES:
Are you legally entitled to work in New Zealand?
New Zealand Citizen
Permanent NZ Resident
Hold NZ work permit (expiry date)
/
/
Are you awaiting a court hearing of any alleged driving or criminal offence which might affect your
suitability for this position, or your ability to effectively carry out the functions and/or duties of the position
applied for?
Yes
No
If answer is yes, please detail:
Do you have any criminal convictions, not including any concealed under the Clean Slate Act?
Yes
No
If yes, please detail:
Do you give us permission to carry out a Police check?
Yes
No
Signature
As part of our Health & Safety programme, we have a zero drug and alcohol policy. If successful for a
permanent position you will need to undergo a drug test. Do you have any reason to believe you would
not pass a drug test now or in the future?
Yes
No
DRIVERS LICENCE:
Do you have a current drivers licence? Yes
No
If yes, what classes of vehicle are you licensed to drive? (Include here if you have provisional or learner
status.)
DECLARATION:
I
declare that the answers to the questions in this application are true and
correct. I understand that if any of the information is proved to be false or misleading, or any relevant
information is left out on this form or any other supporting documents, e.g. CV, then this may lead to my
application being rejected, or if appointed to a position, then I may be instantly dismissed.
Signed:
Date:
Please return to:
FARM\STAFF\RECRUITMENT\ApplicationForm.docx