Personal Details
Full Name
Preferred Name
Email Address
Home Address
Suburb/City
Home Phone Number
Work Phone Number
Mobile Number
Residential Status - Are you legally entitled to work in New Zealand?
Do you have a work visa?
If "yes",
Passport Number(please make sure you enter the full number )
Visa expiry date
Prerequisites
Do you have a full valid New Zealand Drivers Licence or overseas equivalent that allows you to drive in New Zealand?
Is your licence:
A Full New Zealand Drivers Licence?
A Restricted New Zealand Drivers Licence?
A Learners New Zealand Drivers Licence?
Can you drive a manual Car & Van?
Can you drive an automatic Car & Van?
Desirables
Do you have a current First Aid Certificate?(It is a requirement of MASH Trust that you obtain your certificate within three months of commencing employment, training will be provided if needed.)
Do you have or are you working towards a National Certificate or other relevant Qualification?
If so, please specify which:
Do you have a relevant higher tertiary qualification?
If so, then please state:
Availability to Work
If you are successful when are you able to commence work?
MASH Trust provides 24-hour coverage across most of its services, and the position you are applying for may involve rostered shift work.
If this is the case are you prepared to work a variety of shifts?
Have you worked shifts before?
Please state the days you are available to work:
Please state the nights you are available to work:
Remuneration
What is your expected range and form of remuneration?
Range From:
Range To:
Health These will only be considered to the extent that they affect the position applied for. Do you have, or have you ever had, any physical injury that may be aggravated by the requirements of this position or prevent you from carrying out the responsibilities of this position, including but not limited to; any gradual process injury e.g. hearing loss, MSD, back strain or pain? Or are you currently or have you within the past 6 months received any treatment for a physical injury?
If "yes," please give details include what support you may need to fulfil the requirements of this role:
Do you have or have you ever had, a medical condition or an experience of a mental health condition which might be affected by the requirements of this position or prevent you from carrying out the responsibilities of this position? Or are you currently or have you within the past 6 months received any treatment for a medical condition or mental health condition?
If "yes," please give details and include what support you may need to fulfil the requirements of this role:
Have you had any days absent from work due to sickness or accident in the last 12 months?
If "yes," please tick the appropriate box.
You may give details here: If you are offered employment, the offer may be made subject to the satisfactory completion of a medical questionnaire and/or medical examination. Any false or misleading information given in relation to your medical history with regard to gradual process, disease or infection, can result in the loss of entitlement for any compensation from ACC, and may lead to the termination of employment. Employment History Please list your three most recent employers Please complete this section fully, and supply additional employment information in your C.V. 1. Present or most recent employer
Employers Name:
Position held:
From: (date)
To: (date)
Reason for Leaving: 2. Previous employer
Employers Name:
Position held:
From: (date)
To: (date)
Reason for Leaving: 3. Previous employer
Employers Name:
Position held:
From: (date)
To: (date)
Reason for Leaving: Have you or any of your family worked for MASH Trust Board in any capacity?
(If yes, please give details of dates and capacity.):
Do you have secondary employment?
Please give details of any other job / position:: Referees: Please identify three people, who may be contacted by us to act as referees. Please note that at least two of your referees should be people who have managed / supervised your work in your most recent position(s) as listed in your employment history Referee #1
Name
Email
Company
Position
Address:
Daytime Number
Referee #2
Name
Email
Company
Position
Address:
Daytime Number
Referee #3
Name
Email
Company
Position
Address:
Daytime Number
I consent to the management of MASH Trust seeking verbal or written information about me from representatives of my previous employers and / or referees and authorise the information sought to be released. I understand the information obtained from a referee is given in confidence as part of the selection process.
Criminal and Traffic Offence(s) Have you ever
If yes, please provide specific details of all criminal and traffic convictions:
You are not required to declare convictions that would be withheld under the Criminal Records (Clean Slate) Act 2004? To be covered by the Criminal Records (Clean Slate) Act 2004, you must meet all of the following conditions: 1. No criminal convictions within the last seven (7) years, 2. Never have been sentenced to a custodial sentence, 3. Never have been ordered by a Court following a criminal case to be detained in a hospital due to a medical condition, instead of a custodial sentence, 4. Not been convicted of a 'specified offence' (e.g. sexual offending against children, young people or the mentally impaired, 5. Paid, in full any fine, reparation, or cost ordered by the Court in a criminal case, 6. No order has ever been made disqualifying you from holding or obtaining a drivers licence under Section 65 Land Transport Act 1998, or under section 30(a) of the Transport Act 1962
Are you awaiting the hearing of charges in a civil or criminal court of law?
If yes, please provide specific details: Licensing and Vetting Centre (Consent to Disclosure of Information) Any offer of employment made is subject to MASH Trust obtaining information from the Licensing and Vetting Centre. Such an offer of employment or existing employment agreement may be cancelled where advice is received of an existing or imminent criminal conviction.
In respect of any previous criminal convictions or fines for traffic offences that fall outside the MASH Trust Board's criteria, your application will not necessarily be discarded automatically - you will be given an opportunity to discuss the matter before a final decision is made. The Consent to Disclosure of Information Form is held on personal files and is not used for any other purpose.
Should you be accepted for employment, MASH will access your driver licence history from time to time to ensure you maintain a current valid driver licence. By signing this form you consent to this.
Confidential Information provided on this application form is confidential and is collected for the purpose of assessing your suitability for employment in the position applied for. This form will be viewed only by those involved in the recruitment and selection process and the Human Resources Department. If your application is successful this form and supporting documentation will be retained on your personal file. Completion of this form does not indicate that there is any obligation on MASH Trust to employ the applicant.
Declaration I hereby acknowledge that subsequent to the Privacy Act 1993 I am providing personal information to MASH which may or may not be publicly available information, for the purposes of assessment for my prospective employment with MASH.
I declare that the answers I have given to the Criminal & Traffic Offences questions are true and correct to the best of my knowledge. I understand that if MASH employs me and it is found that the information I have provided is untrue or misleading, I may face disciplinary action, which may result in the termination of my employment.
I am aware that the intended recipients of this information are the Human Resources Department, the Management of MASH, the supervisors of the position for which I am applying and anyone else I may authorise disclosure to from time to time.
I further confirm that the information I have provided as part of my application (including but not limited to the answers to the questions in this application, answers given at the interview and in my CV) is accurate, up to date, complete, relevant and not misleading. I understand that if the information I have provided is found to be misleading at any stage or that if any material fact is suppressed I may not be employed or that it would be grounds for MASH to dismiss me if I am employed (such conduct would be considered serious misconduct).
I agree to the above declaration Important Documents
Please upload a copy of your CV:Maximum upload size: 2MB per file.
Please upload your cover letter if you wish to include one:Maximum upload size: 2MB per file.
JD CSW PD 