This information is being collected to ensure that Framework can recruit the best people for any vacant position.  The information you provide will be received and managed by a designated recruitment administrator and members of the recruitment and selection panels.  If your application is successful this form will be retained on your personal file and will be available to authorised Framework management.  If unsuccessful, the form will be destroyed after the vacancy has been successfully filled.  The treatment of any information provided will comply with the Privacy of Information Act 1993.  Information will be stored in secure files.  Any information held by Framework may be corrected on request.  It is Framework's policy to provide equal opportunity for advancement of employees including promotion and training and not to discriminate against any person in accordance with the Human Rights Act 1993.

Any offer of employment is conditional on the satisfactory completion of reference, driver licence and criminal record checks.  Any potential issues arising from these checks may be discussed with you, and if they cannot be resolved satisfactorily, the conditional offer will be withdrawn or your employment contract terminated.

Position Applied for *

If your application is successful, when could you commence employment?

What type of employment contract are you seeking?Permanent Part-TimePermanent Full-TimeFixed TermCasual

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A - Personal Details

First Name

Surname

Preferred Name

TitleMrMrsMsMiss

Home Address

Postal Address

Email Address

Home Telephone Number *

Mobile Number

Work Telephone No

May we contact you at work?YesNo

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B - Work Status & Employment History

Are you legally entitled to live and work in New Zealand?

If you have a work permit, please give details

Do you have any secondary Employment?YesNo

If yes, what position(s) do you hold?

Will you be retaining this/these position(s) if successful?YesNo

If yes, please explain

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1. Present or Most Recent Employer

Company

Address

Position held

Start Date

End Date

Reason for Leaving

Do you consent to Framework contacting your present employer for the purpose of reference checking if you are offered the position? YesNo

If Yes, please give name and contact telephone number of the person we may contact

If not, please state the reason why

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2. Next most recent employer

Company

Address

Position held

Start Date

End Date

Duties

Reason for Leaving

Do you consent to Framework contacting your present employer for the purpose of reference checking if you are offered the position? YesNo

If Yes, please give name and contact telephone number of the person we may contact

If not, please state the reason why

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3. Next most recent Employer

Company

Address

Position held

Start Date

End Date

Duties

Reason for Leaving

Do you consent to Framework contacting your present employer for the purpose of reference checking if you are offered the position? YesNo

If Yes, please give name and contact telephone number of the person we may contact

If not, please state the reason why

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C - Fitness to Undertake Work

Framework is responsible for taking all reasonably practicable steps to ensure the health and safety of everyone in its workplace. We must ensure that all our employees can perform the job-related tasks in a way that does not put themselves or others at risk of harm. To enable us to do this, please answer the following question:

Do you have any injuries, medical conditions, or other personal circumstances that may be aggravated by or affect your ability to do the following tasks?

Driving (manual and automatic cars and vans with passengers)YesNo

Shift work, including weekends, sleep-overs, and awake shiftsYesNo

Supporting people with physical disabilitiesYesNo

Other manual handling tasksYesNo

Working on your ownYesNo

Communicating – verbally or visuallyYesNo

Working in stressful situations, e.g. verbal or physical challenging behaviourYesNo

Working with computersYesNo

If you have answered "Yes" to any of the above, please provide details:

Are you currently taking any medication that may impair your judgement or impact on your ability to effectively carry out the duties of the position applied for?YesNo

If yes, please give details

Do you smoke cigarettes?YesNo

If yes, please be aware that Framework has a smoke free policy. Do you want support to cease smoking?YesNo

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D - Other

Framework uses the Land Transport Driver Check Scheme to help ensure that all employees who drive our vehicles hold a full valid New Zealand driver licence.

Do you consent to Framework checking the details of your driver licence as part of our Selection process?YesNo

Do you hold a current, full New Zealand driver's licence?YesNo

If yes please provide the licence number and the expiry date.

If no, are you legally licensed and able to drive in New Zealand? Please give details of licence held.

Can you hold an every day conversation in a language other than English?YesNo

If yes, please give details

Are there any actions pending which could result in a criminal conviction in NZ or overseas?YesNo

If yes, please give details

Should your application for employment be successful, do you consent to Framework undertaking criminal record checks periodically during the course of your employment?YesNo

Do you have and future holidays booked?YesNo

If yes, please specify the dates

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E - The Position

Why are you applying for this job?

Please describe the skills, experience, competencies and qualifications you hold which are relevant to the advertised position.

Do you have a relative, friend or household member working for Framework? (relative refers to spouse, partner, parent, child, grandparent, uncle, aunt, cousin, or other person related by marriage or common law)YesNo

If yes, please advise the following:

Name

Position

Service

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F - Referees

Please list two employment referees (not members of your family, friend or work colleague) who we may contact on your behalf:

Referee 1

Name

Address

Position

Occupation

Telephone Number

Length of Time Known

Referee 2

Name

Address

Position

Occupation

Telephone Number

Length of Time Known

I consent to Framework seeking verbal or written information on a confidential basis about me from my previous employers and/or referees and authorize the information sought to be released to Framework for the purposes of ascertaining my suitability for the position applied for. I understand that the information received by Framework is supplied in confidence as evaluative material and may not be disclosed to me.

Applicant Name

Date

Do you consent to Framework retaining this application form for future consideration for any other suitable vacancy which may arise within Framework should you be unsuccessful at this time?YesNo

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G - Statement of Agreement

I confirm that to the best of my knowledge the information given, and any documents in respect of this application, are true and correct. I understand that any false or misleading information is given, or any material fact suppressed, I will not be employed, or if I am employed, my employment may be terminated without notice.

Applicant Name

Date

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H - Equal Employment Opportunities Information - Application for Employment

Framework is an Equal Opportunity Employer. The following information is requested to assist in monitoring Framework's Equal Employment Opportunities Policy. This information will not be used in considering your application and will only be used for EEO purposes

Position Applied for

Age GroupingUnder 20 years20-29 years30-39 years40-49 years50-59 years60 years and over

Gender IdentifyMaleFemale

Ethnicity - To which of the following ethnic group(s) do you consider you belong?NZ European/PakehaNZ MaoriPacific IslandAsianAfricanAmericanOther

If Other, please specify

Workforce Profile

What type of organisation do you come from (please select the closest match)?District Health BoardNon Government OrganisationPrivate Hospital HealthcarePrimary Health SectorSocial ServicesDisability Support Service ProviderPublic Sector (non health)Private Sector (non health)Non Labour Market

How did you hear about this Vacancy?Community NewspaperSEEKTrade MeStudent Job SearchFramework Website/IntranetOther

If Other, please specify

Processing

The data has been submitted.