Application Form

Registration

Type of Position(s):	Full Time Part Time Temporary Contract

Surname:

First Names:

Address:

Phone: Business

Private:

Mobile/Alternative:

E-mail Address:

Date of birth:

Current NZ Drivers Licence:

Yes No Other Licences

Qualifications:

Preferred fields of Employment:
Additional Skills:

Have you ever had a work related injury? e.g.

RSI/OOS

Yes

Hearing loss

Yes

Eye loss

Yes

Back injury

Yes

Or any other, please explain:

Are you allergic to, or have any sensitivity to any substance or chemicals?

Yes No
If yes, please explain:

Has your work ever been affected by stress or mental health problems (e.g., depression, anxiety)?

Yes No
If yes, please explain:

Have you ever suffered from long-standing fatigue or tiredness?

Yes No
If yes, please explain:

Additional Comments:

In accordance with The Privacy Act 1993, you are entitled to access this information upon request to this company’s Privacy Officer where the information is held.
I (Full Name)		confirm that the above information is correct.