ࡱ> ^`]@ `1bjbjצצ 4ZD)|||||||4448l(2#) '$B)R+'|'||'X||||  p2l4HXP'0($-$-||||$-|XLd6,*''4X4Petrosell Wanganui Limited Application for Employment * The completion of this form does not indicate that there is any obligation on the employer to engage the applicant. * The applicant understands and accepts that in terms of the Privacy Act 1993, the completion of this form is entirely voluntary and freely consents to providing the information sought by the employer. POSITION APPLIED FOR: ............................................................................ SECTION 1 - PERSONAL INFORMATION (Please Print) First Name(s) Surname  Are you known by any other name(s): Yes / No If Yes, what other name(s) are you known by?  Address: Residential ............................................................................................ ................................................................................................................................ Address: Mailing ...................................................................................................  Date of Birth: .................................................. Telephone Number: ........................................ SECTION 2 - EDUCATION (Including University, Further Education etc) Name of School/College etc.  QualificationsWhat professional, occupational or trade qualifications do you hold? (Attach certificates etc. These will be returned)  SECTION 3 - GENERAL Do you object to enquiries being made of your past, or present employers? Yes / No Are you prepared to work flexible hours? Yes / No Have you worked flexible hours before? Yes / No Have you previously been employed by this employer Yes / No Do you know any person currently employed by this employer? Yes / No If Yes, Who? ...................................................................................... If your application is accepted, when could you commence employment? .............. Have you ever been convicted of a criminal offence in the last 7 years? Yes / No If Yes, give brief details ..................................................................... Are you awaiting the hearing of charges in a court? Yes / No If Yes, give brief details ....................................................................... Do you have any commitments at this time which may prevent you from attending your place of employment in the future? Yes / No If Yes, give brief details ........................................................................ Are you prepared to work additional hours as may be required by the employer? Yes / No Are you prepared to abide by safety and work rules? Yes / No Are you prepared to handle all products, materials or equipment used in the industry including the loading and unloading of any vehicle? Yes / No Are you legally entitled to work in New Zealand? Yes / No SECTION 4 - MEDICAL 1. Have you ever had an injury or medical condition caused by gradual process, disease or infection which may be aggravated or further contributed to by the tasks of position applied for? ....................................................................................................................................................................... 2. We list the following medical conditions as examples of conditions which may be aggravated or further contributed to by the tasks of this job, and we ask that you indicate if you suffer from any of these conditions: Asthma/Bronchitis __ Hayfever/Sinusitis __ Back Trouble __ Skin Problem __ Epilepsy __ Fits/Faints or Blackouts __ Diabetes __ OverUse Syndrome __ Note: This information is relevant to any efforts the employer may take to accomodate your condiitons and ensure that its work place is therefore safe and healthy. SECTION 5 - EMPLOYMENT HISTORY (Start with most recent position) Company:................................................................................Address:.............................................................................................................. From:...................................................................................... To: ........................................................................................................... Position Held: ..................................................................................................................................................................................................... Main Duties: ...................................................................................................................................................................................................... Reason for Leaving: ........................................................................................................................................................................................... Contact Person: .................................................................... Phone No:................................................................................................ Company.................................................................................Address:.............................................................................................................. From: ..................................................................................... To:............................................................................................................ Position Held: ..................................................................................................................................................................................................... Main Duties: ....................................................................................................................................................................................................... Reason for Leaving:............................................................................................................................................................................................... Contact Person: ..................................................................... Phone No:.................................................................................................... Company: ............................................................................... Address:........................................................................................................ From: ...................................................................................... To: ................................................................................................................ Position Held: ......................................................................................................................................................................................................... Main Duties: ........................................................................................................................................................................................................... Reason for Leaving:................................................................................................................................................................................................. Contact Person: ....................................................................... Phone No:..................................................................................................... Company: .............................................................................. Address:........................................................................................................ From: .................................................................................... To: ................................................................................................................ Position Held: ........................................................................................................................................................................................................ Main Duties: ........................................................................................................................................................................................................... Reason for Leaving: ............................................................................................................................................................................................... Contact Person: ..................................................................... Phone No: ................................................................................................... SECTION 6 - DECLARATION This Application Form is a source of information which will be used by the employer and/or its authorised agent to assist it in considering your suitability for the position for which you are applying. If you are successful in obtaining this position, the information will be used to determine your eligibility for promotion (if any) or alternative positions (if any) and where the employer is considering disciplinary action and/or termination in relation to you. This information may be passed on to agencies associated with the employer with regard to employment related matters and/or the employers medical advisor. If you are unsuccessful the information may be retained by the employer (unless you object) for a period of six months in relation to use by the employer for any future vacancies. By signing this declaration you endorse that all information provided by you is true and correct in all respects, and you understand that if any false information is given or material suppressed you may not be accepted, or if employed, may be dismissed. You also authorise the employer or its authorised agent to collect information from any third party including, but not limited to, the referees named on this form. You understand that you are entitled to have access to the information contained on this form, except insofar as it relates to any exemption provided by the Privacy Act 1993. Signature: ...................................................................................... Date: ......................................................................     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