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Application Form

The information in this form is for the purpose of assessing the applicant's suitability for employment by the Rangitikei District Council for the position the applicant is applying. The form is to be personally completed by the applicant. Once you have completed the form, if you wish to attach any additional information you can do so by using the Please Attach Additional Information heading just above the final declaration.


1.If the applicant is attaching a Curriculum Vitae, and that document accurately provides any information sought in this Application, the applicant may note the appropriate question or section “refer attached CV”.

2.Completion of this form does not indicate that there is any obligation on the Council to employ the applicant.



(*) Denotes that these fields are required to be be filled in before the application can be submitted.

Position Applied For (*)

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Where did you learn about this vacancy?

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Section 1 - Personal Information

First Name (*)

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Last Name (*)

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Are you known by another name?

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If, yes, what other name/s are you known by?

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Address (*)

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Postal Address if different from one above

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Phone (Day)

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Phone (Evening)

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Mobile Phone

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Fax

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Email

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Section 2 - Education


Where appropriate, you may be required to produce original qualification documentation.

Name of School/Technical Institute/University

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From - To

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Qualifications Obtained

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Name of School/Technical Institute/University

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From - To

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Qualifications Obtained

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Name of School/Technical Institute/University

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From - To

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Qualifications Obtained

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Section 3 - Skills and Experience

Please list all skills and experience you have relevant to the position applied for

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Section 4 - Employment History

Start with most recent position

1. Name of previous Employer

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Address

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Postion Held

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Nature of Work

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Length of Service (From/To)

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Reason for leaving

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For the purpose of complying with the Privacy Act 1993, do you consent to the Rangitikei District Council contacting your current employer for the purpose of reference checking?

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2. Name of previous Employer

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Address

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Position Held

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Nature of Work

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Length of Service (From/To)

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Reason for leaving

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3. Name of previous Employer

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Address

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Position Held

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Nature of Work

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Length of Service (From/To)

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Reason for Leaving

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Referees (preferably work related)

1. Name

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Address

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Position/Occupation

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Contact No

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2. Name

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Address

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Position/Occupation

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Contact No

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3. Name

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Address

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Position/Occupation

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Contact No

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For the purpose of compliance with the Privacy Act 1993, do you consent to Council seeking verbal or written information on a confidential basis about yourself from representatives of your previous employers and/or referees and authorise the information sought to be released by them to Council for the purposes of ascertaining your suitability for the position you are applying for? Do you understand that the information received by the Council is supplied in confidence as evaluation material and will not be disclosed to you?

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If Yes please type full name

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and Date

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Section 5 - Resident Status

Are you a citizen of New Zealand? (*)

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If no, do you have the right permanent residence or a work permit? (It will be necessary to produce your passport for verification)

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Are you an assisted immigrant under bond to the NZ Government or any other employer?

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If yes, can you produce evidence, if required?

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If yes, do you have authority to accept other employment?

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Section 6 - Interests


Membership of Business, Professional or Trade Organisations

1. Name of Organisation and Office Held

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2. Name of Organisation and Office Held

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3. Name of Organisation and Office Held

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List your hobbies and interests

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Section 7 - General

Do you have a current driving licence? (*)

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If yes, Number

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Type of Licence

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Classes held

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Any demerit points?

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Has your licence ever been endorsed?

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If yes, give brief details

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Do you have any cases pending which would affect your licence?

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If yes, give brief details

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Have you ever been convicted of a criminal offence? (*)

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If yes, give brief details

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Are you currently awaiting the hearing of charges in a civil or criminal court of law? (*)

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If yes, give brief details

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Are you a member of a territorial force unit? (*)

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If yes, have you completed the whole training?

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Please provide any further information as to why you believe you are the most suitable candidate for this position?

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If your application is successful, when could you start work?

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If your application is unsuccessful, do you consent to Council retaining the inforrmation contained in this application form for no more than six months for the purpose of considering your suitability for any other position which may arise with the Council in that time? (*)

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Section 8 - Medical

Tick box which applies and provide details where required

Do you agree to undergo a pre-employment health assessment, if required? (*)

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Do you have any medical condition or injury caused by gradual process, disease or infection (eg hearing loss, sensitivity to chemicals, repetitive strain injuries) that may be exacerbated or further contributed to by the tasks of this job or which may cause harm to others? (*)

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If yes, please detail

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Do you have any medical problems, allergy, disability which could affect your ability to carry out this position effectively? (*)

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Note: if you are in doubt as to whether a problem could affect your ability to carry out this position effectively, specify the problem and state that you are not sure.

If yes, please detail

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Please attach cover letter here (*)

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Please attach CV here (*)

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Please attach additional information here

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I (full name) (*)

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Declare, that to the best of my knowledge, the answers to the questions in this application 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 for employment by Council. If such information or fact is discovered after I have been employed by Council, my employment may be terminated. I also understand any false information given in relation to my medical history may result in my loss of entitlement for any compensation from ACC.

Consent to Declaration (*)

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