Application for Employment
1.
Please complete this application in your own handwriting.
2.
You should provide complete information for each question unless otherwise advised,
regardless of whether you consider it relevant to the position for which you have applied.
Failure to complete this form in a manner required may result in your application being
delayed or declined.
3.
This information is collected to assess your suitability for employment with TAS (which may
include subsequent changes in employment within the organisation). If your application is
successful this form will be retained on your personal file. If unsuccessful it, along with your
other application papers, will be destroyed after three months.
Title (Dr, Mr, Mrs, etc.):
Given name(s):
Surname / family name:
Other name(s) known by or
employed under:
Position applied for:
TAS Team:
I can start on (date/notice):
Residential address:
Suburb and city:
Home phone:
Mobile phone:
Email:
Yes
Are you a NZ Citizen? *
If not, do you have permanent residency in New Zealand? *
If not, are you legally authorised to work in New Zealand? *
Do you hold a full current NZ driving licence?
Do you intend to do other paid or voluntary work while employed here?
Do you have or are you aware of any likely commitments which may prevent
you from attending work during normal business hours (e.g. sports, hobbies,
special interests, education, training, etc.)?
TAS has a Smoke-Free Workplace policy which means there is no smoking on or
around premises. Would this be a problem for you?
* Please provide appropriate evidence
Level 3, 186 Willis Street, Wellington 6011, PO Box 23 075, Wellington 6140, New Zealand
Phone: +64 4 801 2430, Fax: +64 4 801 6230
No
Health Status
A disability or health problem does not preclude full consideration of applications from suitably
qualified people.
Yes
No
Yes
No
Do you have any illness, injury or condition that will prohibit you from doing
the job you have applied for effectively and safely or might require you to
take a significant number of days off work?
If so please give details:
How many days absence in your last 12 months of employment were due to
sickness, injury and/or accident?
Please circle: 0-2 3-5 6-10 11-15 16-20 more than 20
If so please give details:
Have you ever suffered from any gradual process or overuse injuries such as
RSI or OOS (which includes tendonitis, carpal tunnel syndrome, tennis
elbow/epicondylitis etc)?
If YES, please provide details and describe any technical aids, equipment or
adaptations to the workplace which you need to make your work easier
and/or increase your performance:
History
Have you ever been charged with or convicted of a criminal offence?
If yes, further information relevant to your potential employment may be
sought at interview.
Note: you are not required to disclose any charges or convictions that are
eligible to be suppressed under the Criminal Records (Clean Slate) Act
2004.
Has a past employer or professional body taken any disciplinary action or any
legal proceedings (both past and pending) that may effect your ability to
carry out the duties of the position or impact upon your practising certificate
or registration?
If so please give details:
Level 3, 186 Willis Street, Wellington 6011, PO Box 23 075, Wellington 6140, New Zealand
Phone: +64 4 801 2430, Fax: +64 4 801 6230
Referees
In the spaces below, enter the details of two employment related referees who we can contact, i.e. a
manager that you directly reported to. Ideally one will be your current employer, and the second a
recent employer.
First Referee
Second Referee
Name:
Their title at the time:
Company:
Relationship to you:
Length of relationship:
Current phone (DDI & mobile):
Current email:
Conditions of Employment:
1) All information given on this form, and that gathered on personnel files during employment,
may be accessed by TAS management and/or those persons/organisations from which they
may seek advice relative to any matter contained on the individual’s personnel file.
2) Salary, Annual Leave, Sick Leave, Allowances etc are in accordance with the appropriate
employment agreements and relevant TAS policy and procedures.
3) All employees are required to conform to any policies and procedures made by TAS for the
management of services.
4) Tenure: The appointment will generally be subject to a notice period in writing as per the
Individual Employment Agreement. In the event of misconduct or inability to discharge the
duties of the post, an appointee may be suspended from duty at any time and have their
employment terminated on the approval of the Chief Executive.
5) Ongoing education is an integral part of employment and employees are expected to
contribute to, and participate in, appropriate programmes.
Declaration
I, ___________________________________________________________________ (full name)
consent to TAS seeking verbal or written information on a confidential basis from the referees listed
above. Furthermore, I authorise information sought by TAS to be used for the purposes of
ascertaining my suitability for the position I am applying for.
I understand that incorrect or misleading information or information suppressed on this form may
result in being disqualified from appointment, or if appointed, in subsequent dismissal.
Signature: ________________________________________________ Date: _________________
Level 3, 186 Willis Street, Wellington 6011, PO Box 23 075, Wellington 6140, New Zealand
Phone: +64 4 801 2430, Fax: +64 4 801 6230