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Pricks, Losers and Well Poisoners - Book by Dr Steven A Saunders

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Please fill in this form and forward it together with your CV and any other materials you consider relevant, via email address below.

This form and any other material you provide with it, is a source of information which will be used in considering your suitablity for the position for which you were applying.

All fields marked with an astrix * are required.

Contact Details

Position applied for: *

 

Vacancy No: *

 

Your full name:*

 

Age:

 

Full postal address: *

 

Home phone number: *

 

Work phone number: *

 

Mobile phone number: *

 

Email: *

 

Referees

Names of three or four referees whose consent has been obtained and who may be contacted for a confidential reference. (Where possible at least two of the referees should be able to give work related information and should have supervised or been senior to you in your current or most recent employment)

Referee #1

Name: *

 

Address: *

 

Phone: *

 

Mobile: *

 

Email: *

 

Referee #2

Name: *

 

Address: *

 

Phone: *

 

Mobile: *

 

Email: *

 

Referee #3

Name: *

 

Address: *

 

Phone: *

 

Mobile: *

 

Email: *

 

Referee #4

Name:

 

Address:

 

Phone:

 

Mobile:

 

Email:

 

 

Supplementary Information

Do you consent to Steven Saunders & Associated Ltd retaining the information obtained in relation to this application for the purpose of assessing your suitability for other positions for which you may be considered within the next six months? *

Date available to start: (dd/mm/yyyy) *

 

Period of notice required in current employment: *

  
Legal Work Status:  

Are you legally entitled to work in New Zealand? *
As:

Yes No

A New Zealand Citizen *

A permanent resident *

A holder of a current work permit  *

Yes No

Yes  No

Yes No

Medical

If you are offered employment, the offer may be made subject to your obtaining a full medical clearance (by completion of medical examination) to assess your fitness for the job for which you are applying.

Do you consent to undergo a medical examination if you are offered employment? *

Yes No

 

Do you consent to any biological monitoring in accordance with Health and Safety in Employment Act 1992, if applicable? *

Yes No

 

Do you have any health related issues that may impact on your ability to perform the tasks listed in the Job Description and/or Task Analysis for the job that you are applying for? *

Yes No

 

If yes, please give details: 

 

Criminal

Do you have any present criminal convictions, not including any concealed under the Clean Slate Act? *

Yes No

 

Have you ever been disqualified from driving? *

Yes No

 

If yes, please give details:

 

Have you been subjected of a Diversion ordered by the Courts? *

Yes No

 

Are you awaiting the hearing of charges in a civil or criminal court of law? *

Yes No

 

Do you have any legal proceedings against you pending? *

Yes No

 

If yes, please give details:

 

Do you have any secondary employment or business interests that would conflict with your ability to perform in the above position? *

Yes No

 

If yes, please give details:

 

Have you ever been disciplined or dismissed from employment for:

 

Dishonesty or unauthorised possession of company property *

Assault or fighting *

Alcohol or substance absuse *

Yes No

Yes No

Yes No

 

Have you ever had your name changed by statutory declaration? *

Yes No

 

If yes, please give details:

 

The following information is required to assist Steven Saunders & Associates Ltd to meet its obligations under the Health and Safety in Employment Act 1992 and the Accident Rehabilitation and Compensation Insurance Act 1992, and to assess your ability to do the job.

Do you suffer from or have you suffered any injury or medical condition caused by gradual process, disease of infection
(e.g. repetitive strain injury, occupational overuse syndrome, back injury or strain, hearing loss, sensitivity to chemicals) which this job may aggravate or contribute to? *

Yes No

 

If yes, please give details:

 

Do you have any health condition which could affect your ability to do this job? *

Yes No

 

If yes, please give details:

 

Completion of the following information is voluntary. It is collected for statistical purposes to assist with equal employment objectives.

Gender:

Male Female

 

To which of the following ethnic groups do you consider you belong?

New Zealander

Maori

Pacific Island

European

Other, please state:

 

Do you have any health related issues that may impact on your ability to perform the tasks listed in the Job Description and/or Task Analysis for the job that you are applying for?

Yes No

 

If yes, please give details:

 

Do you live with the effects of injury, long term illnes, or disability/disabilities?

Yes No

 

If yes, what do they affect (e.g. movement, hearing, speech)

 

Upload Documents

Upload your CV: *

 

Upload any other material you consider relevant:

 

Declaration

I consent to Steven Saunders & Associates Ltd:

  1. Seeking verbal or written information about me which includes all Professional Memberships and all Tertiary qualifications on a confidential basis and authorise the information requested to be released. I understand that the information will be supplied in confidence as evaluative material and will not be disclosed to me.

  2. Disclosing the information obtained in relation to this application to the prospective employer for the purpose of assessing my suitability for the above position

I understand Steven Saunders & Associated Ltd uses Baycorp Advantage to seek information on me and disclosing the information obtained in relation to this application to the prospective employer for the above position for the purpose of assessing my suitability for that position.

I hereby certify that all information given orally and in writing by me for my application is true and complete to the best of my knowledge and belief. I understand that the provision of false, incomplete or misleading information will be grounds for summary dismissal.

Full Name: *

 

Date: (dd/mm/yyyy) *

 
 
   
  


 

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