Private Bag 9023 | Whangarei 0148 | New Zealand
T: 09 430 4200 | 0800 WDC INFO | 0800 932 463 | F: 09 438 7632
W: www.wdc.govt.nz | E: recruit@wdc.govt.nz
Application for Employment
Date of application
Note
Please forward this completed application form together with a copy of your Curriculum Vitae and/or
introduction letter. The completion of this form does not indicate any obligation on Council to engage the
applicant.
Purpose
In compliance with the Privacy Act the information given in this application is for the purpose of assessing
your suitability for employment with Whangarei District Council (WDC). If you are successful, this material
can also be used in the future for the purposes of transfer or promotion assessment. The form will be
retained on your personal file for access by Human Resources and your Manager. If your application is
unsuccessful it will be kept on file for 12 months and then destroyed.
Position
Position applied for
H
ow did you first learn of this vacancy
WDC website Seek NZ website Whangarei Leader TradeMe Jobs Word of mouth
Employment Agency (please specify)
Other (please specify)
Your name in block letters
Given names (underline name used)
Family name
Your details
Address
Phone no (a/h) Phone no (bus)
Other no (if any) Email
Have you reached the current school leaving age?
Yes No
Are you a New Zealand/Australian citizen?
Yes No
If no, are you:
legally entitled to work in New Zealand?
Yes No
a holder of a current valid residence/work visa?
Yes No
Please note that if successful with your application you will be required to provide WDC with your passport
and visa details before commencing employment.
10/135174 December 2010 2
Employment history
Present or most recent employer
Company
Address
Job held
Main duties
Dates of employment
Reason for leaving
For the purposes of compliance with the Privacy Act 1993 do you consent to
WDC contacting your present employer for the purposes of reference checking?
Yes No
Next most recent employer
Company
Address
Job held
Main duties
Dates of employment
Reason for leaving
Next most recent employer
Company
Address
Job held
Main duties
Dates of employment
Reason for leaving
Skills
Please describe the skills you hold which are relevant to the position applied for (e.g. for Administration – IT
skills and accuracy, for Engineering - project management skills, for Policy research skills, for HR facilitation skills etc)
Customer focus
Customer Service is an integral part of the way we do business. What customer service principles would you
bring to Council if you were successful in your application?
10/135174 December 2010 3
Referees
Give name, address and telephone numbers of at least two referees (preferably from where you have worked
most recently)
Name Position
Address
Phone no Phone no
Name Position
Address
Phone no Phone no
I consent to Council seeking verbal or written information on a confidential basis about me from
representatives of my previous employers and/or referees and authorise the information sought to be released
by them to Council for the purposes of ascertaining my suitability for the position I am applying for.
I understand that the information received by WDC is supplied in confidence as
evaluative material and will not be disclosed to me
Yes No
Signature Date
Education (Including university, further education etc, where applicable)
Qualifications Do you have any other qualifications/certificates/licences or attended any courses
(give details)
General
Have you ever been charged with, or convicted of, a criminal offence (excluding
minor traffic offences)
Yes No
Please be aware that you are not obliged to declare certain offences which occurred more than 7 years ago
under the Criminal Records Clean Slate Act 2004. If you have any doubts, please seek legal advice before
completing this question.
If you answered yes, please provide details
10/135174 December 2010 4
Do you consent to WDC requesting your criminal history from the Privacy Officer
through a criminal reference check?
Yes No
Do you have a current drivers licence?
Yes No
If yes, what class Driver’s Licence no
Full Licence Restricted Licence Learner Licence
Do you have any demerit points or endorsements? (If yes, please provide details)
Please note, if your application is successful, Council will check the validity of your driver’s licence through
Driver Check (an internet site set up by Land Transport New Zealand)
Do you have any relatives, friends or members of your household already
employed by WDC (If yes, please provide details)?
Yes No
Name Relationship
Name Relationship
What are your interests/hobbies/sports/clubs or community activities
Have you ever worked for WDC before? (If so, when)
Yes No
Do you have secondary employment? (If yes, please provide details)
Yes No
Interview arrangements
If you are invited to interview do you have a condition/disability/ illness requiring
special services or facilities? (If yes, please detail)
Yes No
If you are invited to interview do you wish to bring a whanau or support group with
you? (this would be at your own cost)
Yes No
Medical
The purpose of the following questions is to assist WDC to fulfil its legal and ethical responsibilities to
prevent harm to our employees while at work. Dependent upon the range of tasks associated with the job,
or reported medical conditions; you may be requested to undergo a further medical assessment. The
purpose of which is to provide WDC with the additional information we require to assess your ability to carry
out the job safely and without adversely affecting your health.
If you have any concerns or questions, please contact Human Resources, or the Health and Safety
Co-ordinator.
Have you any ongoing health problems that may affect your ability to carry out the
work you have applied for? (If yes, how might WDC reasonably accommodate this
health problem?)
Yes No
(an internet site set up by New Zealand Transport Agency)
10/135174 December 2010 5
Have you had an injury or medical condition caused by gradual process, disease
or infection, for example hearing loss, sensitivity to chemicals, repetitive strain
injuries that may be aggravated or further contributed to by the tasks of this job?
Please refer to the job description. (If yes, please detail)
Yes No
If yes, how might WDC reasonably accommodate this illness/disability/condition?
Have you ever suffered from prolonged backache, back injury or a slipped disc?
Yes No
Are you on any medication that could affect your health and safety, affect your
ability to carry out the work for which you have applied, or affect your ability to get
to/from work? (If yes, please detail)
Yes No
If yes, how might WDC reasonably accommodate this illness/disability/condition?
Have you made any ACC or workplace accident insurance claim for disability (in
the last 5 years) for a condition that might reoccur, or be aggravated by the work
for which you have applied?
Yes No
Do you consent to WDC requesting a report from the ACC, which will give a
history of up to 5 years of your ACC claims?
Yes No
If required do you consent to undergo a medical examination to assess your
fitness for the job to which you are applying?
Yes No
If applicable to your role do you consent to biological & health monitoring in
accordance with the Health and Safety in Employment Act 1992?
Yes No
If you are required to drive a company vehicle, do you suffer from any condition
that could affect, or restrict, your ability to hold a driving licence?
Yes No
In relation to the work, are there any special health/safety considerations you wish
to note or discuss? (If yes, please detail)
Yes No
If applicable to your role, do you suffer from any allergy or asthma?
Yes No
If applicable to your role, have you ever suffered from faints/fits, epilepsy,
blackouts or giddiness
Yes No
10/135174 December 2010 6
Declaration
I, (full name)
declare that to the best of my knowledge the answers in this application and in any other documents
enclosed 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, my employment
will be terminated.
I also understand that any false information given in relation to my medical history with regards to
gradual process, disease or infection can result in my loss of entitlement for any compensation from
ACC. I further understand that any offer of employment if made, may be conditional on my obtaining
full medical clearance.
Signature Date
If your application is accepted, when could you commence employment
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