Employment Application Western Bay of Plenty District Council Which vacancy would you like to apply for? Date: Application Requirements In order to complete this application you are required to: - Have legal entitlement to work in New Zealand - Attach a covering letter of application - Attach your curriculum vitae The information collected on this form is for the purpose of assessing your suitability for employment by the Western Bay of Plenty District Council. Applicants must complete this form personally, answer all questions and accept the declaration. This application should be supported by a curriculum vitae and covering letter. Completion of this form does not indicate any obligation on the Council to engage the applicant. If unsuccessful your application, CV and all other supporting documentation will not be kept longer than 20 days before being destroyed. Legal work status To apply, applicants must be legally entitled to work in New Zealand under current immigration legislation. Are you a New Zealand or Australian Citizen Yes No If you answered no to the question above: - Do you have permanent resident status in New Zealand or Australia? Yes No - Do you have a current work permit entitling you to work in New Zealand? Yes No We may ask you to produce your passport, birth certificate, citizenship certificate or residence permit to show us that you are entitled to work in New Zealand. Information about working in New Zealand can be obtained by visiting New Zealand Immigration Service website at www.immigration.govt.nz How did you find out about this position? WBOP District Council website Newspaper Trademe SEEK Other Application Details Personal Information Title Mr Mrs Miss Ms Surname (legal name) First Name (legal name) Middle Name(s) (legal name) Ethnicity (select from list): African American, Anglo Asian, Asian, Asian Bangladeshi, Asian Indian, Asian Pakistani, Black African, Black Caribbean, Black-Other, Caucasian, Chinese, English, European, German, Hispanic, Indian, Indo European, Latin, Maori, Middle Eastern/Latin American/African, New Zealand, Pacific Peoples, White and Black African, White and Black Asian, White and Black Caribbean, other (if other please specify). Street address Suburb Town/city Postcode Postal address (if different) Email address (Note: email is our preferred method of communication) Form No: 200-9 Page 1
Referees First referee name Relationship to applicant Business Social Family Second referee name Relationship to applicant Business Social Family Third referee name Relationship to applicant Business Social Family I consent to Council contacting my present employer for the purposes of reference checking. Yes No Health and Safety The following information is required to assist Western Bay of Plenty District Council to meet its obligation under the Health and Safety legislation. Confirmation of the appointment of the successful applicant may be subject to the receipt of a satisfactory medical certificate. The cost of the medical examination will be borne by Council. Please indicate whether or not you have any injuries or medical conditions that the tasks of this job may aggravate or contribute to or present you from carrying out the functions of the position. Examples of injuries or medical conditions may be hearing loss, sensitivity to chemicals, occupational overuse injuries or back injuries. Relevant injuries or medical conditions. Yes No If yes please provide details: Criminal Convictions Note: Council requires you to disclose all convictions unless they are covered by the Criminal Records (Clean Slate) Act 2004. You must disclose all of your criminal convictions if you have: Been convicted of an offence within the last 7 years; or Been sentenced to a custodial sentence (eg. imprisonment, corrective training); or Been indefinitely disqualified from driving under the section 65 of the Land Transport Act 1998 or earlier equivalent provision. If you want to know more about the clean slate law, you can seek independent legal advice from a lawyer or community law centre or contact the Department of Labour helpline: 0800 20 90 20. Do you have any criminal convictions? Yes No Do you have any criminal charges pending? Yes No Form No: 200-9 Page 2
Drivers License Are you currently legally allowed to drive in New Zealand? Yes No If yes License number? Indicate which license Full Restricted Learner International Other Do you have any demerit points? Yes No If yes how many? Do you have any cases pending that could affect your license? Yes No We may ask you to produce your drivers license. General Have you previously worked for the WBOP District Council? Yes No Do you have any relatives or know any person currently employed by the WBOP District Council? Yes No. History Present Position List only employment relevant to this application. Previous Employment List only previous employment relevant to this application. Form No: 200-9 Page 3
s List qualifications relevant to this application. Form No: 200-9 Page 4
Attached Documents Letter of application Curriculum Vitae Additional document(s) Declaration 1. All representations, whether oral or in writing, made by me in applying for this position about my qualifications and experience are true and correct and I have not deliberately failed to disclose any matter which may materially influence the Council's decision to employ me. I understand that if any false or deliberately misleading information is given, or any material fact suppressed, I will not be accepted, or if I am employed, my employment will be terminated. 2. I also understand that any false information given in relation to my medical history with regards to gradual process, disease or infection can result in my loss of entitlement for any compensation from ACC. I further understand that any offer of employment if made, is conditional on my obtaining a full medical clearance, if required, through the Western Bay of Plenty District Council's pre-employment medical check by an approved practitioner. 3. Should my application be successful, I give my consent to any vetting processes that Council undertakes which includes employer references and security checks such as (criminal, financial, driver s license status, traffic infringements and dismissal register) and agree to co-operate in providing information to assist that vetting process. 4. I consent to the Western Bay of Plenty District Council seeking verbal or written information on a confidential basis about me from the referees provided and I authorise the information sought to be released by them to the Western Bay of Plenty District Council for the purposes of ascertaining my suitability for this position. I understand that the information received by Western Bay of Plenty District Council is supplied in confidence as evaluative material and will not be disclosed to me. 5. If deemed to be a requirement, I consent to Western Bay of Plenty District Council undertaking pre-employment security checks which include, but are not limited to: NZ Criminal & Traffic Convictions Check (MOJ) Driving License Status & Traffic Infringement History Dismissal Register NZ Immigration Status Check (Visaview) NZ Highest Educational Check Financial Report (if relevant) Please tick Signature Queries to: Human Resources Team (07) 571 8008 Email applications to: hr@westernbay.govt.nz Post applications to: Human Resources Team Western Bay of Plenty District Council Private Bag 12 803 Tauranga 3143 Form No: 200-9 Page 5