Gisborne Hospital Job Application Form

Dear Applicant

Thank you for taking the time to complete this form, which must be completed personally and in full.

All information that you provide is strictly confidential and will not be shown to anyone who is not entitled to see it.

If you are applying for more than one position please complete an application form for each one.

If you are shortlisted for an interview, you will be asked to sign the declaration confirming that the information you provide is accurate.

Personal Details
Vacancy Applied For:
Title:	Dr Mr Mrs Miss Ms
Surname:
First name(s):
Address:
Contact Phone Number:
Email address:
Where did you hear about this vacancy?
Newspaper please specify:
Other Publication please specify:
Internet Site please specify:
Recruitment Agency please specify:
Other please specify:
Employment:	I am a current employee of Tairawhiti District Health
	I have previously been employed by Tairawhiti District Health
	I have never worked for Tairawhiti District Health
Relevant Qualifications
Please only complete this section if not already detailed in your CV. Please include the following information; name of school/institution, qualifications gained, the level completed and the year completed
Secondary Schooling:
University or Polytechnic:
Other Qualifications/Seminars Completed:
Employment History
Please only complete this section if not already detailed in your CV. Please include the following details; organisation, your position title, date commenced, date finished, your responsibilities/duties and your reason for leaving
Current/Most Recent Employer:
Previous Employer:
Other Employers:
Authority to Practice
Do you have a current New Zealand Annual Practising Certificate (APC)/Registration?:	Yes No
If yes it is a requirement that you attach a copy of your APC noting the first year of registration:
If no have you applied for the appropriate APC/Registration?:	Yes No
Professional
Have you ever been denied Professional Registration or had Registration removed?:	Yes No
Has there ever been notification to your Registration Body regarding your Standards of Practise or Health?:	Yes No
Please give brief details::
Work Related Referees
Current/Most Recent Manager
Reference 1 Name:
Reference 1 Organisation:
Reference 1 Position:
Reference 1 Address:
Reference 1 Phone Number:
Reference 1 Email:
Previous Manager/Clinical Leader
Reference 2 Name:
Reference 2 Organisation:
Reference 2 Position:
Reference 2 Address:
Reference 2 Phone Number:
Reference 2 Email:
Declaration
Do you consent to Tairawhiti District Health contacting your current most recent or previous employers or other people in confidence for the purposes of reference checking?:	Yes No
It is policy that successful applicants undergo a health screen as a precondition of employment Do you consent to undergo a health screen if you are offered employment by Tairawhiti District Health? :	Yes No
Tairawhiti District Health is committed to being a smoke free environment Do you smoke?:	Yes No
Tairawhiti District Health is committed to the Treaty of Waitangi and actively promotes a philosophy of cultural best practice to its Maori population If successful in gaining employment would you be prepared to undergo cultural safety training?:	Yes No
Are you legally permitted to work in New Zealand? If yes and you are an overseas applicant please ensure you attach a photocopy of your work visa/permit:	Yes No
If no please detail:
Is it a requirement of your position to hold a current New Zealand Driving Licence? If yes please ensure you attach a photocopy:	Yes No
Have you ever had any injury or medical condition caused by gradual process disease or infection for example sensitivity to chemicals repetitive strain injuries (RSI or OOS) hearing loss that may be aggravated or further contributed to by the tasks of this job? :	Yes No
If yes please detail:
Have you ever had a manual handling strain or injury to your back? :	Yes No
If yes please provide brief detail:
Have you ever had an ACC or other type of compensation claim for an injury or illness?:	Yes No
If yes please provide details:
Do you have any problem/s that will affect your ability to perform the duties of the position you are applying for?:	Yes No
If yes please give details:
I declare that the information I have given is correct and understand that any incorrect or misleading information may lead to disqualification, or if appointed, termination of employment
Name:
Date:
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