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Application for Employment

* Compulsory field

Position applied for:	*
	Student employment
How did you find out about this position?

PERSONAL INFORMATION
Title:
Surname:	*
First names:	*
Preferred name:	*
Other names you are known by:
Contact details
Residential:
Postal (if different):
After work:
Work phone:
Mobile:
Email:	*
How would you like to be contacted?
GENERAL INFORMATION
What work experience do you have that is most relevant to this role?

What qualifications do you have that are most relevant to this role?

What position do you currently hold?

How long have you been in your current position?

Do you speak or read any languages other than English?
	Yes No
Please give details:
Are you legally allowed to work in New Zealand?
	Yes No
If yes, are you:

A New Zealand/Australian citizen	Yes No

A permanent resident	Yes No

A holder of a current work permit	Yes No
If yes, what dates?
Date issued:
Date expiry:
What type of work permit?
Passport number and country of origin:

Are you an assisted immigrant under bond to the government or any other employer?
	Yes No
If you are invited to interview, you will be required to present your passport prior to the interview.

COUNCIL RELATIONSHIPS
Have you previously worked for or applied for a job with New Plymouth District Council?
	Yes No
Please give details:
Do you have a spouse / partner / relative or household member currently employed by NPDC with whom you may have a working relationship if you are appointed?
	Yes No
Please give details:

Do you have a spouse / partner / relative or household member currently elected as a NPDC councillor or community board member with whom you have a working relationship with if you are appointed?
	Yes No
Please give details:

Do you have a spouse / partner / relative who has a business relationship with NPDC that could create a conflict of interest if you are appointed?
	Yes No
Please give details:
AVAILABILITY FOR EMPLOYMENT
If offered this position do you intent to engage in any other paid work?
	Yes No
Please give details:

Do you have any committments that may prevent you from attending your place of employment during ordinary hours of work or affect your availability for overtime/out of hours work?
	Yes No
Please give details:

If accepted, when could you start?

DRIVING
Do you have a full current driver's licence?
	Yes No
If yes, what classes?
Date issued:
Expiry date:
Does your licence have any demerit points for endorsements?
	Yes No
Are you awaiting hearing of any charges for driving offences?
	Yes No
Please give details:

CONVICTIONS AND PROCEEDINGS
Have you ever been convicted of a criminal offence or are you awaiting charges in a criminal court of law? (This does not include convictions that are subject to the clean slate scheme of the Criminal Records (Clean Slate) Act 2004.)
	Yes No
Please give details:

If offered appointment, do you agree to authorise the council to obtain a copy of personal information held on you by the Department of Courts?
	Yes No

HEALTH
Have you had, or do you have, an injury or medical condition caused by gradual process disease or infection (e.g. hearing loss, sensitivity to chemicals, repetitive strain injuries) that the tasks of this job may aggrevate or contribute to?
	Yes No
Please give details:

Have you had an ACC claim in the last five years?
	Yes No
Please give details:
Would you require any alterations or additions to your work area in order to perform your duties satisfactorily?
	Yes No
Please give details:

A pre-employment medical examination by our council doctor and/or occupational health consultant will be a final prerequisite for applicants. Drug testing will be undertaken at pre-employment. At any stage during your employment if an accident/incident/near miss occurs and/or there is reasonable cause which gives rise to the suspicion that an employee was or is abusing any illegal drug or substance and/or unauthorised consumption of alcohol, further testing will be undertaken.
Are you prepared to undertake a pre-employment medical assessment including a drug screening test?
	Yes No
In the event of an accident/incident/near miss occurring during your employment and/or there is reasonable cause which gives rise to the suspicion of the usage of illegal drug or substance and/or alcohol consumption, do you consent to undergo a drug test?
	Yes No
Refusal to undertake the test or a positive result from such a test will be grounds for not employing the applicant.
Are you prepared to abide by the requirements of the Health and Safety in Employment Act 1992 and subsequent regulations?
	Yes No
Proof of Hepatitis A and Hepatitis B immunity status is required. Are you prepared to provide proof of your immunity status at pre-employment and at any time during your employment?
	Yes No

FINANCIAL
Have you entered into bankruptcy or any material accommodation with creditors?
	Yes No
Please give details:

OTHER
Are there any other issues, such as disciplinary or dismissal matters, that would have a bearing on your appointment?
	Yes No
Please give details:

INTERVIEWS
As part of its commitment to the Treaty of Waitangi and in line with its Equal Employment Opportunities Policy, New Plymouth District Council invites applicants who are shortlisted for interview to bring whanau or support people to the interview.
If you are interviewed, do you wish to bring whanau/support people with you?
	Yes No

DECLARATION
I declare that, to the best of my knowledge, the answers to the questions in this application are correct. I understand that if any false information is given or any material fact withheld, I may not be accepted, or if I am employed, I may be dismissed. *

Covering Letter (max. size 5MB)
CV (max. size 5MB)	*
Email me a copy of my application

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