Century Drilling &
Energy Services (NZ) Limited
Tel: +64 7 376 0422
Fax: +64 7 374 8508
info-nz@mbcentury.com
APPLICATION FORM
Attached is an Application for Employment form which you are requested to complete
personally.
The application form is a source of information, which will be used by the Company to
assist it in considering your suitability for the position for which you are applying. If
successful, such information shall form part of the Company’s personnel records.
Failure to supply the information requested would prejudice the Company’s ability to
assess your suitability for the position.
Any offer of employment is made subject to your completing the Company’s preemployment health assessment to its satisfaction.
You are entitled to access this information upon request to the Company’s Privacy
Officer.
Their location is:
166 Karetoto Road
SH1 Wairakei
Taupo
Or
PO Box 341
Taupo 3351
Provided that information relating to unsuccessful applicants shall be retained by the
Company for a period of 12 months. The above information is provided in accordance
with the Privacy Act 1993.
166 Karetoto Road, Wairakei 3337, New Zealand.
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PO Box 341, Taupo 3351, New Zealand
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CONFIDENTIAL
To be completed personally by Applicant
Date of Application:
Application for Employment
Note:
The completion of this form does not indicate that there is any obligation on the company to
engage the applicant.
Purpose:
This information is collected for the purpose of assessing your suitability for employment at
Century Drilling & Energy Services (NZ) Ltd which may include subsequent changes in
employment with the company.
MB Century use only
Review Date
Name
Signature
Comments
PLEASE PRINT
Position Applied For:
Your Name
In block letters
How do you like to be addressed:
Family Name:
Given Names (underline name used):
Are you known by any other name(s)?
Your Contact Address and
Telephone Numbers
Contact Address:
Home Phone No:
Other No. (If any):
Email Address:
Do you consent to the Company using this email address to email
you documents:
Yes/No
Have you reached the current school leaving age?
Legal Work Status
Yes/No
Are you legally entitled to work in New Zealand?
As:
A New Zealand Citizen?
Yes/No
A permanent resident?
Yes/No
*A holder of a current work visa?
*If Yes please provide a copy of your current work Visa
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Yes/No
Education
Including university, further
education, etc where applicable
Name of secondary school(s) attended
Education (continued)
Qualifications
( NCEA, School Certificate, University Entrance, Bursary) – Subjects
Please provide certified copy of
Tertiary and professional
qualifications
Other Tertiary & Professional qualifications
Yes/No
PLEASE ATTACH CERTIFIED COPIES
Languages
Can you hold an every day conversation in any language other than
English? If yes, what languages?
--------------------------------------------------------------------------------------------
Apprenticeship
For trades positions only
Do you have your apprenticeship papers?
PLEASE ATTACH CERTIFIED COPIES.
Yes/No
In what trade were you apprenticed?
What was the name and address of the employer?
Name:
Address:
What trade qualifications do you hold (i.e. Trade Cert, Advanced
Trade Cert., etc)?
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Driving Licence/s
Do you have a current drivers licence?
Yes/No
If yes, what class/es?
Drivers Licence No.:
Drivers Licence Version No.:
Do you have any demerit points or special conditions?
Yes/No
Do you have any cases pending?
Yes/No
If yes, please detail
For the purposes of compliance with the Privacy Act 1993 do you
consent to the Land Transport NZ (LSTA) releasing to the Company
information regarding your Driver Licence
Yes/No
Curriculum Vitae (CV)
PLEASE PROVIDE A CURRENT C.V.
Qualifications
DO YOU HAVE A NZQA NATIONAL STUDENT NUMBER (NSN)?
Attached
Yes/No
NSN Number:
PLEASE PROVIDE A CURRENT PRINTOUT OF NZQA
“RECORD OF ACHEIVEMENT” Attached
Yes/No
DO YOU HAVE ANY OF THE FOLLOWING QUALIFICATIONS?
PLEASE ATTACH COPIES.
Forklift (OSH)
Expiry Date: ____/____/____
First Aid Cert (US6400,6401,6402)
Expiry Date: ____/____/____
Basic Life Support
Expiry Date: ____/____/____
Basic First Aid
Expiry Date: ____/____/____
Fire Fighting
Expiry Date: ____/____/____
Confined Space
Expiry Date: ____/____/____
Working at Heights/Fall Arrest
Expiry Date: ____/____/____
Breathing Apparatus (CABA)
Expiry Date: ____/____/____
WELDING TICKETS (PLEASE SPECIFY)):
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DO YOU HAVE ANY OTHER QUALIFIACTIONS/CERTIFICATES
LICENCES/ OR ATTENDED ANY COURSES?
PROVIDE DETAILS INCLUDING DATE OF ATTAINMENT & EXPIRY DATE
WHERE APPLICABLE & ATTACH COPIES.
PLEASE DESCRIBE THE SKILLS YOU HOLD WHICH ARE
RELEVANT TO THE POSITION APPLIED FOR
Medical History
Employment History
Please provide details of any medical conditions or previous injuries
that will affect your ability to carry out the position work requirements.
Present or Most Recent Employer:
Company:
Address:
Job Held:
Main Duties:
No of hours worked per week: ……… Length of Service: …………..
Reason for Leaving:
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For the purposes of compliance with the Privacy Act 1993 do
you consent to the Company contacting your present employer
for the purposes of reference checking at the point that a job
offer is
made to you?
Yes/No
Next Most Recent Employer
Company:
Address:
Job Held:
Main Duties:
No of hours worked per week:
Length of Service:
Reason for Leaving:
Next Most Recent Employer
Company:
Address:
Job Held:
Main Duties:
No of hours worked per week:
Length of Service:
Reason for Leaving:
Give details of any other job which may be relevant:
Have you ever worked for this Company or an associated
Company before?
Yes/No
If yes, where and when:
Do you have secondary employment?
If yes, please detail:
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Yes/No
Referees
Give name, address and telephone numbers of at least three
referees.
Name:
Position:
Address:
Phone Number:
Name:
Position:
Address:
Phone Number:
Name:
Position:
Address:
Phone Number:
I, ____________________________ consent to the Company seeking verbal or written
information on a confidential basis about me from representatives of my previous employers
and/or referees and authorise the information sought to be released by them to the
Company for the purposes of ascertaining my suitability for the position for which I am
applying. I understand that the information received by the Company is supplied in
confidence as evaluative material and will not be disclosed to me.
If yes, Signature:
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____/____/____
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General
Are you prepared to work shifts if required to do so?
Yes/No
Have you worked shifts before?
Yes/No
Are you prepared to work overtime, including weekends if
required?
Yes/No
Have you been convicted of a criminal offence?
Yes/No
If yes, please detail:
Have you been the subject of a Diversion ordered by the
Courts?
Yes/No
Are you awaiting the hearing of charges in a civil or criminal
court of law?
Yes/No
Are you prepared to handle all products, materials, or
equipment used in the industry?
Yes/No
Do you have a spouse, partner, relative or household-member
working here or elsewhere in the industry?
Yes/No
If yes, who?
Where?
What transport arrangements do you have to attend your place of
employment?
Can you think of anything that may affect your regular attendance at
work?
Yes/No
If yes, please detail:
What are your interests/hobbies/sports/clubs or community
activities?
If your application is successful when could you commence employment?
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Medical
If you are offered employment the offer is made subject to your
obtaining a full medical clearance following the completion of our preemployment medical.
Do you agree to undergo a medical examination?
Yes/No
Do you consent to any biological monitoring if applicable to
the Job? (Refer HASE Act)
Yes/No
Have you had an injury or medical condition caused by gradual,
disease or infection for example hearing loss, sensitivity to
chemicals, repetitive strain injuries that may be aggravated or
further contributed to by the tasks of this job?
Yes/No
If yes, please detail:
Do you consent to the Company retaining the information contained
in this application form for the purposes of considering your suitability
for any other position which may arise with this Company in the
future?
Yes/No
Declaration
I,
(full name) declare
that to the best of my knowledge the information provided in this
application and in any resume enclosed is accurate and I understand
that if any false or misleading information is given, or any material
fact suppressed, I will not be employed, or if I am employed, my
employment will be terminated. I further understand that any offer of
employment if made is conditional on my obtaining a full medical
clearance through the Company’s pre-employment medical.
Signed:
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EQUAL EMPLOYMENT OPPORTUNITIES
Questionnaire
The Company has an Equal Employment Opportunity (EEO) Policy and is keen to
develop appropriate equal opportunities practices that benefit everyone in the work
place.
To do this we need to collect statistical information to measure progress towards
achieving our EEO goals, in this instance to assess who the Company is attracting,
as applicants for positions.
The completion of this form is on a voluntary basis, and if you have any objection to
providing this information, there is no compulsion on you to comply with this
request.
1.
Position applied for
______________________________
2.
Date of Birth
______________________________
3.
Gender
______________________________
4.
What is your present
marital status?
______________________________
What ethnic group
do you belong to?
______________________________
Describe any disability
or impairment that
you might have.
______________________________
5.
6.
7. (a) How did you find out
about this position?
______________________________
(b) Publication name
______________________________
(c) Other Source
______________________________
In terms of the Privacy Act 1993 this information will only be used for the purposes
stated.
Please return this form with your application.
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