SECTION A: APPLICANT’S PERSONAL DETAILS

Name

First Name^* 

Surname^* 

Known As 

Previously used name(s) 

Address^* 

 

City^* 

Country 

-select-AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Antarctic TerritoryBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanton and Enderbury IslandsCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos [Keeling] IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicCôte d’IvoireDenmarkDjiboutiDominicaDominican RepublicDronning Maud LandEast GermanyEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesFrench Southern and Antarctic TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau SAR ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMetropolitan FranceMexicoMicronesiaMidway IslandsMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar [Burma]NamibiaNauruNepalNetherlandsNetherlands AntillesNeutral ZoneNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth VietnamNorthern Mariana IslandsNorwayOmanPacific Islands Trust TerritoryPakistanPalauPalestinian TerritoriesPanamaPanama Canal ZonePapua New GuineaParaguayPeople's Democratic Republic of YemenPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSpainSri LankaSudanSuriTextSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaSão Tomé and PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Minor Outlying IslandsU.S. Miscellaneous Pacific IslandsU.S. Virgin IslandsUgandaUkraineUnion of Soviet Socialist RepublicsUnited Arab EmiratesUnited KingdomUnited StatesUnknown or Invalid RegionUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWake IslandWallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands

Post code 

Home Phone^* 

Work phone 

Mobile Phone^* 

Email^* 

SECTION B: RIGHT TO WORK IN NEW ZEALAND

Are you legally entitled to work in New Zealand? ^*  

-select- Yes No

If yes, please tick which of the following applies to you:  

-select- NZ Resident Work visa/Permit

Expiry Date  

Please bring your Passport, Birth Certificate or work visa to any interview  

SECTION C: EMPLOYMENT HISTORY

PRESENT EMPLOYER

Name 

Location 

Position 

Employed from 

Contact person 

Relationship 

Phone number 

Employed till 

Reason for leaving  

Do you authorise PSS to contact the above employer to obtain references about you?  

-select- Yes No

_____________________________________________________________________________________________________________________________________________________  

PREVIOUS EMPLOYER (MOST RECENT)

Name 

Location 

Position 

Employed from 

Contact person 

Relationship 

Phone number 

Employed till 

Reason for leaving  

Do you authorise PSS to contact the above employer to obtain references about you?  

-select- Yes No

_____________________________________________________________________________________________________________________________________________________  

PREVIOUS EMPLOYER (NEXT MOST RECENT)

Name 

Location 

Position 

Employed from 

Contact person 

Relationship 

Phone number 

Employed till 

Reason for leaving  

Do you authorise PSS to contact the above employer to obtain references about you?  

-select- Yes No

_____________________________________________________________________________________________________________________________________________________  

OTHER REFEREES

Please list other referees that Presbyterian Support Southland can contact to discuss you and your ability to perform the role.  

Name 

Relationship 

Phone Number 

Name 

Relationship 

Phone Number 

_____________________________________________________________________________________________________________________________________________________  

WORK ABSENCES

Have you been absent from work in the last 12 months, other than for annual holiday?  

-select- Yes No

If yes, please provide details  

_____________________________________________________________________________________________________________________________________________________  

DISMISSALS

Have you ever been dismissed from employment or resigned as an alternative to dismissal?  

-select- Yes No

If yes, please provide brief details  

SECTION D: QUALIFICATIONS, SKILLS AND PROFESSIONAL MEMBERSHIP/REGISTRATION

Do you have a current NZ Driver's licence?  

-select- Yes No

Please bring your Driver's licence to any interview to be photocopied.  

Do you consent to PSS accessing your Driver's Licence record using NZTA Driver Check Service?  

-select- Yes No

Please list all qualifications you have, relevant to the position you are applying for  

Please list all skills you have, relevant to the position you are applying for  

Please list all professional memberships, license and/or registrations you have  

Name of professional body 

Name of professional body 

Expiry date 

Expiry date 

Please attach current copies of qualifications/certificates/Professional membership/registration/license to this application form.  

SECTION E: PREVIOUS ASSOCIATION WITH PRESBYTERIAN SUPPORT SOUTHLAND

Have you worked for Presbyterian Support Southland before?  

-select- Yes No

If yes, Position 

When 

Location 

Have you applied for a position with Presbyterian Support Southland before?  

-select- Yes No

If yes, Position 

When 

Location 

Do you have a spouse, partner, relative or household member working with Presbyterian Support Southland? If yes, please provide brief details  

SECTION F: CONFLICTS OF INTEREST

Are you aware of any other factors that could place you in a potential conflict of interest with Presbyterian Support Southland?  

-select- Yes No

If yes, please provide details  

SECTION G: PROFESSIONAL CONDUCT

Have you ever been the subject of a disciplinary investigation or a professional disciplinary inquiry in New Zealand or another country?  

-select- Yes No

If yes, please provide details  

SECTION H: MEDICAL HISTORY

Do you have any health problem or disability which could affect your ability to perform for the role applied for or to undertake the required duties for the hours required?  

-select- Yes No

If yes, please provide brief details  

Have you had an injury, or a medical condition caused by gradual process, disease, or infection which the position applied for may aggravate or contribute to?  

-select- Yes No

If yes, please give details  

If you have said "Yes" to question 1and I or 2 above, is there anything we can do to assist you (e.g.) a need for special equipment?  

-select- Yes No

If yes, please give details  

Have you had, or been exposed to, any infectious or notifiable diseases (e.g. including, but not limited to, MRSA, Hepatitis A and B, TB)?  

-select- Yes No

If yes, please give details  

If you are shortlisted for appointment, do you agree to undergo a medical examination, including a drug and alcohol test, should Presbyterian Support Southland consider such tests to be relevant to the position? The tests and/or examination would be conducted by a medical practitioner nominated by Presbyterian Support Southland.  

-select- Yes No

If you are appointed do you agree to drug & alcohol testing as stipulated in PSS Drug & Alcohol policy?  

-select- Yes No

If you are appointed do you agree to having an influenza vaccination at our expense?  

-select- Yes No

If you are appointed do you agree to having MRSA test at our expense?  

-select- Yes No

SECTION I: MEMBERSHIPS, INTERESTS AND ACHIEVEMENTS

List the major interests and activities that you are involved in, or have undertaken, in the last three years (e.g. club or team membership, volunteer activities) which you consider may be relevant to your application  

SECTION J: CRIMINAL RECORD

I authorise Presbyterian Support Southland (or its agent) to request and obtain a criminal history check from the Department of Justice  

-select- Yes No

SECTlON K: CREDIT CHECK

I authorise Presbyterian Support Southland (or its agent) to request and obtain all information concerning my credit status, should the position within PSS hold significant financial authority.  

-select- Yes No

SECTlON L: CHILD YOUTH AND FAMILY CHECK (For Family works Staff only)

I authorise Presbyterian Support Southland (or its agent) to request and obtain a Child Youth and Family check from the Ministry of Child Youth and Family if applicable for my role.  

-select- Yes No

SECTION M: AVAILABILITY

If your application is successful, when would you be able to commence employment?  

Do you have any commitments that may affect your ability to perform the role applied for (e.g. sports, community service commitments)?  

-select- Yes No

If yes, please give details  

Do you know of any other reason why, if appointed, you would be unable to attend work regularly or undertake the required duties for the hours required  

-select- Yes No

If yes, please give details  

SECTION N: DECLARATION

IMPORTANT PLEASE READ CAREFULLY BEFORE SUBMITTING

1. l have completed this application form myself without assistance from any other person.  

2. I certify that the information I have given in this Application for Employment form is true and correct. I understand that if I have given incorrect or misleading information or if I have left out any important information, I may not be considered for appointment, or if appointed to a position, I may be dismissed from employment for provision of incorrect information.  

3. I understand that the information in this application form will remain confidential to Presbyterian Support Southland. If my application is successful, this information will become part of Presbyterian Support Southland’s permanent records. If my application is unsuccessful I note that the information in this form will be retained in a secure file for six months unless I specify otherwise, and will then be confidentially destroyed.