Application for Employment Form

Please complete the entire form
and double check before pressing
the submit button.

Date of application

Position applied for

Preferred location
(please tick the boxes of the clinics
where you would like to work)

Hours available to work
(please tick box to indicate total
hours available to work per week)

Full name

Address

Home phone

Other phone

Email address

Have you reached the current school leaving age (16 years)?	YES NO
Are you legally entitled to work in New Zealand?	YES NO
Current status	NZ citizen Permanent resident Hold a current work permit

Clinical applicants only:
Do you have a current APC?	YES NO
Do you have indemnity insurance?	YES NO

General:
Are you prepared to work shifts if required to do so?	YES NO
Are you prepared to work weekends if required to do so?	YES NO
Are you prepared to work overtime if required?	YES NO
Do you have any present criminal convictions, not including any concealed under the Clean Slate Act?	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 and equipment used in the industry?	YES NO

Medical:
Do you have any health related issues that may impact on your ability to perform the tasks listed in the job description for job that you are applying for?	YES NO
If yes, please detail
Have you ever worked for White Cross Healthcare before?	YES NO
If yes, where and when?
Do you have secondary employment?	YES NO
If yes, please detail

Availability and Expected Remuneration:
If your application is successful, when can you commence employment?
What level of remuneration, are you seeking? Please specify, cash and non-cash components?

Qualifications – please complete if not already detailed in your CV
Qualification (e.g. School Cert, U.E.)	Subjects






Do you have any other qualifications/certificates/licences/or attended any courses? (give details)
Please describe the skills you hold which are relevant to the position applied for (e.g. for a typist - typing speed, word processing capability, shorthand capability, etc).
Languages - list any languages that you can hold an every day conversation in, other than English

Referees - please give details of at least two referees
Full Name	Contact details (telephone & email)	Relationship

	Yes, I consent to the above organisation seeking verbal or written reference on a confidential basis about me, and authorise the information sought to be released 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.

Employment History - please complete if not already detailed in your CV

Current Employer
Company
Position held
Main duties
Hours per week
Length of service
Reason for leaving

Declaration
	I declare that to the best of my knowledge the information provided in this application and in any resume 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 may be terminated. I further understand that any offer of employment if made, is conditional on my obtaining a full medical certificate if required and requested by White Cross Healthcare Ltd.