Application for Employment 2017


 1. Personal Details:

Title:
Surname:*
First Name:*
Preferred Name:
Date of Birth:*
Gender:*
Nationality:
Ethnicity:
Home Phone:
Mobile Phone:
Address:*
Town:*
Email:

  2. Emergency Contact Details:

Surname:*
First Name:*
Relationship to you:*
Phone Number:*

 3. Health and Safety

Do you have a medical, allergic, physical condition or injuries that may affect your ability to effectively carry out your duties?
If yes please provide details:
Are you currently receiving medical treatment or are you taking prescription medicine?
If yes please provide details:
Do you need to bring prescription medicine to work?
If yes please provide details:
Do you have a hearing disability?
If yes please provide details:
Have you ever suffered a back injury?
If yes please provide details:
Have you ever claimed compensation from ACC?
If yes please provide details:

If you are offered employment, the offer may be subject to your obtaining a full medical clearance (by completion of medical examination) to assess your fitness for the job for which you are applying. Do you consent to undergo a medical examination if you are offered employment?

 4. Employment Details

Have you worked in a Packhouse before?
If yes, where?
If yes, What Role:
Previous Employer Name:
Previous Employer Phone Number:
Previous Employment Position:
Reason for leaving:
Packhouse Location*
Position Applied For:
Preferred Shift:
I agree I can work all the hours and days required including weekends:
If NO, Please provide details
Are you Legally Entitled to work in NZ
If yes, select which applies
Visa Expiry Date:

 5. Skills and Licences

Licence/Certificate e.g. First Aid/Forklift:
Licence Number:
Expiry Date:
Licence/Certificate e.g. First Aid/Forklift:
Licence Number:
Expiry Date:

 6. Payroll Details

IRD number:
Tax Code:
Bank Name and Branch:
Bank Account Number:
Are you currently receiving Work and Income benefits:
Are you a member of Kiwisaver?
Percentage Amount:

 7. Employee Suitability for Food Handling

Have you been diagnosed with any infectious disease or blood borne infections, or suffered persistent vomiting or diarrhea in the last 12 months, which we need to be aware of for food safety requirements?
If yes, please provide details

 8. Criminal Offences

Do you have any criminal convictions? Do not include any concealed under the Criminal Records (Clean Slate) Act 2004:
If yes please provide details:
Are there any charges pending against you?
If yes, please provide details:

9. Declaration and Consent

A:I consent to EastPack seeking information, on a confidential basis, about me from any previous employers or referees and authorize the information sought to be released for the purposes of ascertaining my suitability for the position for which I am applying. The information received by EastPack is supplied in confidence, and evaluative material will not be disclosed. I also consent to EastPack seeking information from Government Agencies or providing information to Government Agencies for employment related purposes.

B: I understand that EastPack may require me to attend an unpaid-pre-season assessment training session, and that any payment for further training in a specialist role (e.g. QC or EDI) will be at EastPack’s discretion and would only be made if I was offered, and began, employment.

C: For the purpose of providing a safe and healthy workplace, I acknowledge that I may be asked to undergo a pre-employment drug test. Re-fusal to undergo a drug test or a failed test will result in me not being employed. If I am employed before the results of my pre-employment drug test are available and/or receive a failed result, then my employment will terminated immediately

D: I understand that EastPack may take a digital photo of me for security and identification purposes. I understand that EastPack may also complete a security check with the New Zealand Police.

I declare that all information supplied in this application is true and correct and I understand that if any incorrect, misleading or suppressed information on this form or on any other document provided to EastPack in any form whatsoever by any means, may lead to disqualification, or if appointed, to termination of employment.

  I agree to the terms above*