Application for Employment
EMP03
Version 1.0
August 2013
Page 1 of 10
Position Applying
For
PERSONAL DETAILS
YOUR NAME
Mr
Mrs
Miss
Other
First
names
Surname
Address
STREET
Town/City
Postal
Town/City
Contact
numbers
(
)
(
)
(
)
Home
Work
Mobile
Email
Address
Date of Birth
/
/
Are you legally entitled to work in New Zealand?
Do you have a current driver’s licence?
Yes
Yes
Drivers licence number
Classes Held
Endorsements Held
No
No
Version number (5b)
Expiry date
D
1
F
2
P
3
R
Have you ever had any driving convictions?
If yes, please list court convictions
/
4
T
Yes
Do you hold a current OSH Forklift Certificate?
Yes
Do you hold a current First Aid Certificate?
Have you been convicted of a criminal offence in the last 7 years?
Are you awaiting trial for a criminal offence?
Do you have any court convictions?
Yes
Yes
Yes
Yes
/
5
6
V
W
No
No
Expiry
/
/
No
Expiry
No
No
No
/
/
Application for Employment
EMP03
Version 1.0
August 2013
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If yes, please list court convictions
Are you currently bound by diversion compliance imposed by a court of law?
If yes, please give details
Yes
EDUCATION DETAILS
Secondary School(s)
1.
Years attended:
from
to
from
to
2.
Years attended:
No
Application for Employment
EMP03
Version 1.0
August 2013
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University/tertiary institution(s) attended
1.
Years attended:
from
to
Degree/diploma/qualifications gained
Do you have any other studies planned?
Yes
No
If so, give details
Other qualifications
Have you sat other examinations or attended any other courses (business and educational) not mentioned above?
Membership of technical/professional bodies
COMPUTER SYSTEMS EXPERIENCE
Please list relevant details on computer systems and software packages that you have had experience with or have used in your
previous employment
CAREER OBJECTIVES
What is your present career objective?
Remuneration package being sought?
Geographical location required and why?
EMPLOYMENT HISTORY
Present/or last position
Company/organisation
Address
Number of employees
Position(s) held
Responsible to (name and title)
Dates of employment (month & year)
Outline of duties and responsibilities
Application for Employment
EMP03
Version 1.0
August 2013
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Reason for leaving
Notice required
Previous Positions
Company/organisation
Position(s) held
Responsible to (name and title)
Dates of employment (month & year)
Outline of duties and responsibilities
Reason for leaving
Company/organisation
Position(s) held
Responsible to (name and title)
Dates of employment (month & year)
Outline of duties and responsibilities
Reason for leaving
Other positions (give brief details on any other position held)
Company
Position(s) held
Dates of employment (month & year)
Reason for leaving
REFEREES
Nominate three references, both business and professional
Name
Position
Company
Telephone
(
)
(
)
(
)
Name
Position
Company
Telephone
Name
Position
Company
Telephone
LEISURE INTERESTS
Outline leisure interests both sporting and cultural
Application for Employment
EMP03
Version 1.0
August 2013
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Application for Employment
EMP03
Version 1.0
August 2013
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OTHER RELEVANT INFORMATION
In the space provided, please supply any other information relevant to your application. Include information regarding the type
of position sought, reasons for this application, your career aims, perceived strengths and weaknesses, and any other details that
may be of assistance your application
Application for Employment
EMP03
Version 1.0
August 2013
Page 7 of 10
HEALTH & SAFETY DETAILS
The following information is required to assist Hilton Haulage Ltd to meet its obligations under the Health and Safety in
Employment Act 1992 and subsequent amendments and the Injury Prevention Rehabilitation and Compensation Act 2001, and to
assess your ability to perform the duties of the position safely.
It is important that you let us know of any health issues or disability that you have that is relevant to the role that you are applying
for. Letting us know that you have a medical condition or disability will not exclude you from being considered for this position.
Do you know of any health problems that would affect your ability to safely work for Hilton Haulage Ltd?
Yes
No
Have you ever had heart disease, blood pressure problems, chest pains or palpitations (an irregular or rapid heartbeat)?
Yes
No
Have you ever had muscle, bone, joint, ligament or tendon problems, eg arthritis, tendonitis, broken bones or joint injury?
Yes
No
Have you ever had back pain or any sort of back or neck problems?
Yes
No
Have you had an injury or medical condition caused by gradual process, disease, or infection, e.g. hearing loss, sensitivity to
chemicals, repetitive strain injuries, which the tasks of this job may aggravate or contribute to?
Yes
No
Have you ever had a stroke of any sort or ever experienced sudden tingling, numbness or loss of feeling in your arms, hands,
legs, feet or face?
Yes
No
Have you ever had any episodes of loss of consciousness, dizziness, vertigo, fainting, fits, turns or seizures of any sort?
Yes
No
Do you have diabetes, asthma, epilepsy or other long-term health problems?
Yes
No
Do you suffer from Rheumatoid Arthritis?
Yes
No
Do you regularly take any prescription medication?
Yes
No
Do you regularly take any non-prescription medication?
Yes
No
Do you have any problems with your vision or hearing?
Yes
No
Do you regularly exercise for 30 minutes or more, three times per week?
Yes
No
Do you smoke?
Yes
No
Have you made any ACC claims in the past five years?
Yes
No
If you have answered yes to any of the above questions, please provide details
I,
(full name) declare that, to the best of my knowledge the information provided
in this application for employment (including my CV) is accurate, complete and correct and I have not omitted any information that
could affect Hilton Haulage Ltd’s decision to employ me.
Under the Privacy Act 1993, I understand that the information provided by me in this application is being collected for the purposes
of determining my suitability for employment. I acknowledge that should the information requested not be provided by me, this
application may be rejected. I give my authority to contact any third party mentioned in this application form to verify that the
information is correct.
By signing this application for employment, I authorise Hilton Haulage Ltd to complete a driver’s licence check with the Land
Transport New Zealand, Transport Organisation Registry Online (TORO), for the purposes of checking licence status (including
suspension), licence classes held, endorsements held and demerit point totals for the suitability of employment.
I authorise Hilton Haulage Ltd to seek verbal information about me from my nominated referees, to help assess my suitability for
employment. I understand that the information provided is evaluative and will not be released to me.
I agree to notify the employer of any change to my medical condition likely to have an effect on the current activities of work.
SIGNED
Heard about this vacancy through?
__________________________________
DATE SIGNED
The Press
Ashburton Guardian
Word of Mouth
Job Week
Company Employee
Hilton Haulage Web
Other ___________________________________
___/___/____
The Timaru Herald
Trade Me
Seek
Application for Employment
EMP03
Version 1.0
August 2013
Page 8 of 10
CONSENT AND DECLARATION – PRE-EMPLOYMENT DRUG TESTING
The Employers’ policy on drug and alcohol in the workplace requires that prospective employees must return a negative drug test
before they can be employed.
Please read and acknowledge the terms and conditions set out below.
Consent and Declaration
Should it be requested I agree to provide a specimen of urine for drug testing and authorise MEDLAB to conduct a urine drug test.
I ____________________________________________________ consent to my urine being tested for the following:






Cannabinoids
Opiates
Cocaine
Amphetamines
Benzodiazepines
Other substances that may affect my ability to work safety
NB - Certain prescribed and over the counter medication may affect your results. You may wish to advise on this form any medication
you are currently taking which you think might affect your results.






I understand that a refusal to be tested will mean my application for the role will not be progressed
I understand that if I return a positive result an offer of employment that has been made may be withdrawn
I understand that submission of an adulterated sample, diluted sample, of one with an invalid temperature may result in
withdrawal of an employment offer that may have been made
I understand that I am required to provide this sample within 2 days of receipt of this form and that I will be given only two
opportunities to supply this sample and that this must be done within 24 hours from my initial attempt
I understand MEDLAB are acting as agents for Hilton Haulage Ltd and acknowledge the procedure has been explained to
me to my satisfaction.
I authorise the Authorised Testing Agent (e.g. ESR) to communicate the result to management at Hilton Haulage Ltd.
In all other respects the results shall remain confidential.
SIGNED
__________________________________
NAME (Please Print)
__________________________________
DATE SIGNED
Administration Only
Date/Time sample collected: __________________________This form was issued on:
Candidate Name:
_____________________
_____________________________________________________
___/___/____
Application for Employment
EMP03
Version 1.0
August 2013
Page 9 of 10
Application for Employment
EMP03
Version 1.0
August 2013
Page 10 of 10