Application for Employment · Web viewApplication for Employment. EMP03. Version 1.0. August 2013. Application for Employment. EMP03. Version 1.0. August 2013. Page 2 of 8

Application for Employment EMP03

Version 1.0 August 2013Page 1 of 9

Position Applying For

PERSONAL DETAILSYOUR NAME Mr Mrs Miss Other

First names

Surname

AddressSTREET

Town/City

Postal

Town/City

Contact numbersHome

( )

Work( )

Mobile ( )

Email Address

Date of Birth / / Are you legally entitled to work in New Zealand? Yes NoDo you have a current driver’s licence? Yes No Version number (5b)

Drivers licence number Expiry date / /

Classes Held 1 2 3 4 5 6Endorsements Held D F P R T V W

Have you ever had any driving convictions? Yes NoIf yes, please list court convictions

Do you hold a current OSH Forklift Certificate? Yes No Expiry / / Do you hold a current First Aid Certificate? Yes No Expiry / / Have you been convicted of a criminal offence in the last 7 years? Yes NoAre you awaiting trial for a criminal offence? Yes NoDo you have any court convictions? Yes No

If yes, please list court convictions

Are you currently bound by diversion compliance imposed by a court of law? Yes NoIf yes, please give details



EDUCATION DETAILSSecondary School(s)

1. Years attended: from to 2. Years attended: from to



University/tertiary institution(s) attended1. Years attended: from to

Degree/diploma/qualifications gained

Do you have any other studies planned? Yes NoIf so, give details

Other qualificationsHave you sat other examinations or attended any other courses (business and educational) not mentioned above?

Membership of technical/professional bodies

COMPUTER SYSTEMS EXPERIENCEPlease list relevant details on computer systems and software packages that you have had experience with or have used in your previous employment

CAREER OBJECTIVESWhat is your present career objective? Remuneration package being sought? Geographical location required and why?

EMPLOYMENT HISTORYPresent/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 Reason for leaving Notice required

Previous PositionsCompany/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

REFEREESNominate three references, both business and professional

Name Position Company Telephone ( )



LEISURE INTERESTSOutline leisure interests both sporting and cultural



OTHER RELEVANT INFORMATIONIn 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



HEALTH & SAFETY DETAILSThe 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 NoHave you ever had muscle, bone, joint, ligament or tendon problems, eg arthritis, tendonitis, broken bones or joint injury?

Yes NoHave you ever had back pain or any sort of back or neck problems?

Yes NoHave 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 NoHave 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 NoHave you ever had any episodes of loss of consciousness, dizziness, vertigo, fainting, fits, turns or seizures of any sort?

Yes NoDo you have diabetes, asthma, epilepsy or other long-term health problems?

Yes NoDo you suffer from Rheumatoid Arthritis? Yes NoDo you regularly take any prescription medication? Yes NoDo you regularly take any non-prescription medication? Yes No Do you have any problems with your vision or hearing? Yes NoDo you regularly exercise for 30 minutes or more, three times per week?

Yes NoDo you smoke? Yes NoHave 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 __________________________________ DATE SIGNED ___/___/____

Heard about this vacancy through? The Press Ashburton Guardian The Timaru Herald



Word of Mouth Job Week Trade Me Company Employee Hilton Haulage Web Seek Other ___________________________________



CONSENT AND DECLARATION – PRE-EMPLOYMENT DRUG TESTINGThe 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 DeclarationShould 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 __________________________________ DATE SIGNED ___/___/____

NAME (Please Print) __________________________________

Administration Only

Date/Time sample collected: __________________________This form was issued on: _____________________

Candidate Name: _____________________________________________________



Documents

Application for Employment · Web viewApplication for Employment. EMP03. Version 1.0. August 2013. Application for Employment. EMP03. Version 1.0. August 2013. Page 2 of 8