Port Nelson Limited Application Form

Transcription

1 Port Nelson Limited Application Form Surname: First Name: Street Address: City: Postal Code: Home Number: Work Number: Mobile Number: Position Applied For: If you are making a general enquiry about work, what areas are you interested in? Please tick appropriate boxes. Stevedoring ICT Marine Security Human Resources Workshop Finance & Admin Drivers ie. Crane, Forklift Logistics Any specific roles you are interested in within these areas: Office Use Only

2 Resident Status Are you legally entitled to work permanently in New Zealand? YES NO If not, for what length of time are you entitled to work in New Zealand? (please attach evidence) Drivers Licence Do you hold a current NZ Drivers Licence? YES NO If yes, what class(es)? Do you have any licence restrictions? YES NO If yes, please list Have you ever been disqualified from driving? YES NO If yes, why? Do you have any current demerit points against your licence? YES NO If yes, how many? What other types of licences do you hold? Criminal Convictions Have you been convicted of a criminal offence or have a court case that is, or could be pending? YES NO If yes, please detail: We undertake criminal conviction history checks for all appointments. You are required to provide your approval to access your criminal convictions history from the Ministry of Justice. Are you agreeable to this? YES NO Medical Have you had an injury or medical condition caused by gradual process, disease or infection, such as repetitive strain injury, that the tasks of this job may aggravate or contribute to? YES NO If yes, please detail: Have you ever suffered from a back injury or back strain that the tasks of this job may aggravate or contribute to? YES NO If yes, please detail: Are you aware of, or being treated for, any current or former medical or health related condition, illness, injury or disability that may affect your ability to carry out the requirements of the job applied for or that may be aggravated or further contributed to by the tasks of the job? YES NO If yes, please detail: You will be required to undertake a pre-employment medical examination that tests for drugs, alcohol, vision and hearing. Are you agreeable to this? YES NO (costs to be met by Port Nelson Ltd) To be successful in your application for employment with Port Nelson Ltd the checks/tests must be completed to Port Nelson Limited s satisfaction. The information gathered from the assessments will be used by Port Nelson Limited solely for the purpose of determining your suitability for the role.

3 Secondary Education School: Location: Period of Attendance: Qualification Received: (if qualification not gained, please list classes passed) Tertiary Education Institution/Polytechnic: Location: Period of Attendance: Qualification Received: (if qualification not gained, please list papers passed) Other Qualifications (e.g. Forklift license; marine tickets, trade certificates) Employment History Please attach/provide a CV or complete the following information. Please list your employment history starting with your most recent or current job and work back-wards through your career. Start Date: Finish Date: Current Employer s Name & Location: Nature of Business: Position Title Current Salary: Reason for Leaving: Start Date: Finish Date: Employer s Name & Location: Nature of Business: Position Title Reason for Leaving: Start Date: Finish Date: Employer s Name & Location: Nature of Business: Position Title Reason for Leaving:

4 References Please provide two of your most recent business referees. Reference 1: Name: Company: Position: Years Acquainted: Contact Details: Reference 2: Name: Company: Position: Years Acquainted: Contact Details: Hours & Days Are you available for shiftwork (different hours / days) YES NO What days and hours are you available to work? Please tick where appropriate. Dayshift Nightshift Monday Tuesday Wednesday Thursday Friday Saturday Sunday What type of working arrangement are you looking for? Please tick where appropriate. Permanent Full Time Casual Permanent Part Time Fixed Term Any General Have you ever had a dispute with an employer, or been subject to disciplinary action, or have disciplinary action pending by an employer? YES NO If yes, please detail: Have you ever worked for PNL before? YES NO If yes, please detail including reason for leaving: What are your salary or hourly wage expectations? When would you be available to commence employment?

5 Disclosure of Interest Do any members of your family (including your partner or spouse) work for Port Nelson Ltd? If yes, please detail: YES NO Do you currently undertake secondary employment or plan to undertake Secondary employment while employed at Port Nelson Ltd? YES NO If yes, please detail: Why are you looking to join Port Nelson Ltd? Please detail: The facts set out by me in this application are true to the best of my knowledge and belief. I hereby authorise my former employers and referees to give any information regarding my employment with them, and in addition, to furnish any other information they may have concerning me. I understand that misrepresentation or omission of factual information on this application is cause for dismissal. I also understand that any false information given in relation to my medical history may result in loss of entitlement for any compensation from ACC. I acknowledge and understand that in accepting employment from Port Nelson Ltd, I will comply with the Company s various policies and procedures including the Drug and Alcohol testing programme. In making this application, I warrant that: All representations or statements I have made to the Employer in making application for the employment are true and correct; I have not deliberately failed to disclose any matter that may have materially influenced the Employer s decision to employ me; I do not have any contractual commitments that would conflict with the performance of my duties and obligations in the position. Signed Date

6 ACC 6213 Pre-employment check - request for ACC claims history Please Read: Please complete this form and then it to preemploymentchecks@acc.co.nz. Please provide a valid proof of identification: These include but are not limited to; Driver s Licence, Passport, 18+ Card, Birth Certificate, or Statutory Declaration signed by the Police or JP. Employers and recruitment agencies: unless the job applicant gives specific permission, the claims history provided will not include information about any: mental injury as a consequence of physical injury claims declined claims including accredited employer claims treatment injury claims claims occurring more than 10 years ago PART A: IDENTIFYING DETAILS sensitive claims wilfully self-inflicted claims accidental death claim dependants 1. J O B A P P L I C A N T S D E T A I L S PLEASE COMPLETE ALL SECTIONS First Name: Middle Name: Surname: Date of Birth: Also known as (e.g Maiden name): Phone Number/s: Ethnicity: Male Female Mailing address: Suburb : Town/City: Postal Code : Previous Address: Type of work/industry: 2. E M P L O Y E R O R R E C R U I T M E N T A G E N C Y D E T A I L S FOR ACC CLAIMS HISTORY RESULTS TO BE SENT TO Organisation Name: Port Nelson Ltd Contact Phone Number: Contact Person s Name: Suzanne Thompson Contact Address: suzanne.thompson@portnelson.co.nz PART B: CONSENT FOR ACC TO RELEASE INFORMATION 3. J O B A P P L I C A N T S C O N S E N T A N D S I G N A T U R E I authorise ACC to release my ACC claims history to the employer or recruitment agency named in Part A:2, and understand that I will be sent a copy to the mailing address marked in Part A:1. I understand that this information will only be used to decide whether I can carry out the job safely. I understand I have the right: to see and correct this information under the Privacy Act 1993 that the employer or recruitment agency will use this information responsibly, and comply with the Privacy Act 1993, Health Information Privacy Code 1994 and the Human Rights Act 1993 that the employer or recruitment agency will destroy the information once the job application process is complete. Job applicant s signature: Date: ACC6213 January 2014 Page 1 of 1

7