APPLICATION FOR EMPLOYMENT

CONFIDENTIAL To be completed personally by Applicant

Note: The completion of this form does not indicate that there is any obligation on the Company to
engage the applicant.
Purpose: This information is collected for the purpose of assessing your suitability for employment at
which may include subsequent changes in
employment with the Company.
PLEASE PRINT

POSITION APPLIED FOR

YOUR NAME How do you like to be addressed:

Given Names (underline name used):

Are you known by any other name(s)?

Give details:

YOUR CONTACT ADDRESS Contact Address:

AGE Have you reached the current school leaving age (16 years)? Yes/No

LEGAL WORK STATUS Are you legally entitled to work in New Zealand? Yes/No

A New Zealand Citizen Yes/No

A permanent resident Yes/No

A holder of a current work visa Yes/No

EDUCATION Name of secondary school(s) attended

Other Qualifications Yes/No (Subjects)

LANGUAGES Can you hold an every day conversation in any language other than English?

APPRENTICESHIP Do you have your apprenticeship papers? Yes/No

What was the name and address of the employer?

Name Address

What trade qualifications do you hold? (i.e. Trade Cert, Advanced Trade Cert.,
etc)?

QUALIFICATIONS Do you have any other qualifications/certificates/licences/or attended any

.
Please describe the skills you hold which are relevant to the position applied for
(e.g. for a typist - typing speed, word processing capability, shorthand capability,
etc).

EMPLOYMENT HISTORY Present or Most Recent Employer

Company:

Address:

Job Held:

Main Duties:
No of hours worked per week: Length of service:

Reason for Leaving:

For the purposes of compliance with the Privacy Act 1993 do you consent to the
Company contacting your present employer for the purposes of reference checking?
Yes/No

Next Most Recent Employer

Company:

Address:

Job Held:

Main Duties:

No of hours worked per week: Length of service:

Reason for Leaving:

Next Most Recent Employer

Company:

Address:

Job Held:

Main Duties:

No of hours worked per week: Length of service:

Reason for Leaving:

Give details of any other job which may be relevant:

Have you ever worked for this Company or an associated company before?Yes/No

If yes, where and when:

Do you have secondary employment? Yes/No

If yes, please detail:

Name Position Address Phone No.

If your application is successful when could you commence employment:

GENERAL Are you prepared to work shifts if required to do so? Yes/No

Have you worked shifts before? Yes/No

Are you prepared to work overtime if required? Yes/No

Do you have any present criminal convictions,

Have you been the subject 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

Are you prepared to handle all products, materials, or equipment used in the
industry? Yes/No

Do you have a current drivers licence? Yes/No

If yes, what class?

Drivers Licence No.:

Do you have any demerit points or endorsements? Yes/No

Do you have any legal proceedings against you pending? Yes/No

If yes, please detail:

If yes, who?

Where?
 What transport arrangements do you have to attend your place of employment?

What are your interests/hobbies/sports/clubs or community activities?

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?

Do you consent to any biological monitoring in accordance with the 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 job that you are
applying for? Yes/No

If yes, please detail:

DRUG TESTING Prior to an offer of employment, you will be required to undergo pre employment
drug screen. Should you return a non negative result to the initial screen test,
you will not be offered employment or any provisional offer of employment will
be withdrawn..

I agree to undergo pre employment drug testing and for the results to be
released to A S Wilcox & Sons Ltd. I understand that any offer of employment
made will be withdrawn should a not negative result be reported.

_________________________________ Date: ___________________________

Name of organisation:

I consent to the above organisation seeking verbal or written reference on a confidential basis from________________
(person) of ____________________ (organisation) about me, and authorise the information sought to be released for the
purposes of ascertaining my suitability for the position for which I am applying. I understand that the information received
by the Company is supplied in confidence as evaluative material and will not be disclosed to me.

Signature of candidate: Date:

Declaration/Consent
I _________________________________________________________________________(please print full name)
Declare that to the best of my knowledge the answers, whether in this application, the interview process, or my CV, are
correct and 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, the Company may terminate my employment with immediate effect. I also
understand that any false information given in relation to my medical history may result in my loss of entitlement for any
compensation for work-related injury in accordance with the Accident Insurance Act 1998.

If my application is not accepted, I consent to the company retaining the verbal or written information about me on a file
for a period of 12 months from the date of this application. Such information may be referred to if possible job
opportunities arise during that period.

Signature: _____________________________________________ Date: ________________________________

OFFICE USE ONLY

Successful  Starting date if successful: _______________ Rate of Pay: $ _______________

Area: Packing  Splitting  Washline  Job Description: ___________________________

Fixed Term  Finish Date: _______________ On Call  Permanent 