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 do not have a CV please complete the "Previous Employment" section of this form.

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

If you are unable to complete the form electronically, a printable version is available by opening the
Printable Application form (PDF)

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

* Indicates Mandatory Questions and/or Sections.

POSITION APPLIED FOR

Job Title *
Position Number *
First Name *
Preferred Name
Surname (Family name) *
Daytime Contact Phone *
Business Phone
Alternative Contact
Fax
E-mail *
Address *
Postcode
Are you currently employed with Waikato District Health Board *	Yes No

Have you previously worked for Waikato District Health Board?*

Yes No

EDUCATION / QUALIFICATIONS ACHIEVED, OR PARTLY COMPLETED

Degree, Diploma, Certificates Secondary School Subjects & Grade if that is your highest level of achievement	Where Completed and Year Completed
1
2
3
4

AUTHORITY TO PRACTICE

Do you have a current New Zealand Practising Certificate/Registration?

Yes No

If no, have you applied?

Yes No

If appointed please produce originals for sighting.

IMMIGRATION STATUS *

Are you legally entitled to work in New Zealand

Yes No

Please select one that applies to you: New Zealand citizenship      New Zealand residency     Work visa/permit? If you have a work/visa permit, when will it expire? If appointed please produce originals of documentation for sighting.

REFEREES

Please provide accurate names and postal addresses of three people who have agreed to act as your referee and from whom we may request a reference report. (Referees will need to be in a position to comment on your employment history/education/clinical abilities).

By supplying the names of these people Waikato District Health Board will:

(i) assume that you have advised and given these referees your permission for them to disclose information about you to Waikato District Health Board.

(ii) seek information from these referees on the basis that the referees will supply the information in confidence as evaluative material for the purposes of the Privacy Act 1993 and that any information supplied by the referee will not be disclosed to you should you request access to it.

Note: These obligations of confidence are subject to any requirement Waikato District Health Board has under the Official Information Act 1982, to disclose the information to you.

Referee 1
Name Address Position of referee (eg employer, etc)	Day Phone Email Night Phone Fax No. Alternative Contact No.

Referee 2
Name Address Position of referee (eg employer, etc)	Day Phone Email Night Phone Fax No. Alternative Contact No.

Referee 3
Name Address Position of referee (eg employer, etc)	Day Phone Email Night Phone Fax No. Alternative Contact No.

HEALTH STATUS

Are there any health and safety accommodations that you believe Waikato District Health Board needs to be aware of in regard to the position you have applied for?

Yes No

If yes, please give details

Note: In some situations further specific medical information relating to the requirements of the position will be needed. Therefore, if offered employment, you may be required to undertake a pre-employment medical examination. In this case, a satisfactory report will be a condition of employment.

APPLICATION SUPPORT

In support of your application, tell us how you will add value to the delivery of care and/or services at Waikato District Health Board. Please provide evidence of how you meet the key competencies for the position applied for.

CONVICTIONS *

Have you ever been convicted of a criminal offence?

Yes No

If yes, please give details

Are you awaiting the hearing of charges in court?

Yes No

If yes, please give details

PROFESSIONAL DISCIPLINE *

Have you been subject to professional disciplinary inquiry or have knowledge of an event that might give rise to disciplinary inquiry?

Yes No

If yes, please give details

CURRENT NEW ZEALAND DRIVERS LICENCE

Category	Please Select Provisional Full Other	Date Issued
Number	Classes	Expiry Date

APPLICATION INFORMATION

How did you first learn of this vacancy?	Please select Newspaper Ad Journal / Newsletter Ad Internet Site Employment Agency Personal Enquiry Other e.g. Career Expo, please specify:
Attach Your Covering Letter Here:
Attach Your CV Here:

GENERAL INFORMATION

If you are invited to attend an interview, you may wish to bring a support person/s with you. If this is so, you are required to confirm who will be accompanying you.
Pre-employment health screening information is requested on separate documents.

THE PRIVACY ACT

Waikato District Health Board will not use or disclose information provided, except for the purposes described below and as permitted by the organisation’s Human Resource Privacy Policy.

This includes using the information in the process of determining your suitability for the position you have applied for with the Waikato District Health Board and if you are appointed for personnel management purposes (Waikato District Health Board staff associated with administering these processes/purposes will have access to the information).

Failure to supply any of the information requested may prejudice the Waikato District Health Board's ability to assess your suitability for the position you have applied for.

The Waikato District Health Board may seek independent corroborating evidence or material on this application form or CV provided to support the application.

If your application is unsuccessful then the information will be destroyed in a secure manner and your CV returned.

If your application is successful, then the information will be retained in the Staff Records of the Waikato District Health Board under conditions which ensure security.

You may request access to and correction of your staff record, by writing to the Privacy Officer, Waikato District Health Board, PO Box 934, Hamilton.

DECLARATION *

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, to termination of employment.

Name    Date

If you require any further information please contact the Recruitment Centre.

 

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