Role Applied for
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Date
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MM
DD
YYYY
Name
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First Name
Last Name
Email
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Mobile Phone
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Country
(###)
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Do you have permanent residency in New Zealand or are legally entitled to work in New Zealand?
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Do you have a current and valid driver’s license?
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Do you have any criminal convictions or court action pending?
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If yes, please provide detail. We may check this on police.govt.nz/service/vetting)
Do you give permission for Lake Taupō Hospice to carry out a police check?
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Have you had any injury, or do you have a medical condition caused by a gradual process, disease or infection which maybe aggravated by carrying out the tasks the role applied for requires? Examples of such medical conditions may include hearing loss, sensitivity to chemicals, occupational overuse/repetitive strain injuries, stress or depression.
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Do you have any health or physical condition which may affect your ability to effectively carry out the tasks and responsibilities of the role applied for?
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Do you agree to attend a medical practitioner and/or to undergo pre- employment drug or alcohol testing, if requested by Lake Taupō Hospice?
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Do you agree to undergo a drugs and alcohol test, if requested, by Lake Taupō Hospice?
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Referee 1 Name
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First Name
Last Name
Referee 1 Phone
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Country
(###)
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Referee 1 Nature of Relationship
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Referee 2 Name
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First Name
Last Name
Referee 2 Phone
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Country
(###)
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Referee 2 Nature of Relationship
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Referee 3 Name
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First Name
Last Name
Referee 3 Phone
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Country
(###)
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Referee 3 Nature of Relationship
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Job 1 Employer
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Job 1 Role Held
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Job 1 Top Three Key Responsibilities
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Job 2 Employer
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Job 2 Role Held
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Job 2 Top Three Key Responsibilities
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Job 3 Employer
Job 3 Role Held
Job 3 Top Three Key Responsibilities
What is your highest level of education?
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Please list other relevant qualifications
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By typing my name below I declare that the information I have provided in this application are true and correct. I understand that if any of the information provided on this form, my CV and/or cover letter is proved to be false or misleading, of if any relevant information has been omitted then my application may be rejected or if appointed into a role with Lake Taupō Hospice that it may lead to termination of my employment.
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