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Te Hauora O Te Hiku O Te Ika Trust
APPLICATION FOR EMPLOYMENT

This is an Application for Employment form which provides us with important information about you personally and which assists Te Hauora O Te Hiku O Te Ika Trust (the Trust) in considering your suitability for the position for which you are applying.  The form is an application only and does not give rise to any obligation by the Trust to employ you.  If your application is successful, the information shall form part of the Trusts’ personnel records.  Failure to supply the information requested may prejudice the Trusts’ ability to assess your suitability for the position.  You are entitled to access this information on request.  Completed application forms are held by the People and Performance team.

APPLICATION DETAILS
NAME & CONTACT DETAILS:
IWI / HAPU AFFILIATIONS
DRIVERS LICENCE
Do you agree for a copy of your NZ driver’s license to be provided to Te Hiku Hauora’s Operations team for Te Hiku Hauora fleet car purposes?
CRIMINAL CONVICTIONS
The Trust has a smoke and vape free policy and a smoke and vape free programme, Toki Rau available at no cost if required with regular support and assistance.
EMERGENCY CONTACT DETAILS
PRIMARY EMERGENCY CONTACT
SECONDARY EMERGENCY CONTACT
LEGAL WORK STATUS
Have you reached the current school leaving age?
Are you legally entitled to work in New Zealand?
What is your current status?
If you are not a New Zealand citizen, please provide evidence of your legal entitlement to be in New Zealand.
If you intend to apply for New Zealand residence, please specify:
AVAILABILITY FOR WORK
Do you have any commitments which mean you may be unavailable or unable to perform the required work, for example, sporting, community service or territorial army?
If ‘YES’, please provide details including the nature of the commitment and the date, length of time for which you will be unavailable.
QUALIFICATIONS, TRAINING, LICENCES
Please list below any of your school, tertiary, professional, trade or any other qualifications that are relevant to this application.
Do you have a current Safe Working Practices Certificatea current CPR certificate?
Do you have a current CPR certificate?
Do you have a current First Aid Certificate?
List any other qualifications relevant to the position.
HEALTH AND SAFETY
Are you prepared if required?
To provide information regarding your health and to undergo a medical examination, including drug tests by a medical professional nominated by the Trust relating to your ability to perform satisfactorily and safely the tasks of the position to which this application relates?
To participate in regular health monitoring (e.g., hearing test, vision screening, blood/urine screening, chest x-ray etc.) to assess the effects on your health, if any, from the environment of the job to which this application relates?
Do you have any known condition which may affect your ability to effectively carry out the functions and responsibilities of the position applied for?
If, ‘YES’, please provide details:
Have you had any work-related injuries during the past five years?
If, ‘YES’, please provide details:
The Trust takes the health and safety of its working environment and staff seriously. An offer of employment (and ongoing employment with the Trust) is conditional on the Applicant being honest and upfront with all health-related matters that may impact on your ability to fulfil your employment commitments and obligations.
EMPLOYMENT HISTORY
Please provide details for your current / last three employers.
Key duties/Responsibilities:
Reason for leaving
Key duties/Responsibilities:
Reason for leaving
Key duties/Responsibilities:
Reason for leaving
Have you previously been employed by Te Hauora O Te Hiku O Te Ika?
Do you have secondary employment?
OTHER:
Why are you applying for this position?
What interests you about working for Te Hauora O Te Hiku O Te Ika?
What knowledge, skills, and attributes do you believe you can bring to this position?
Do you have any family members who are currently employed by Te Hauora O Te Hiku O Te Ika? If, ‘YES’, please list their names below and what your relationship is with them:
REFEREES
Give names and telephone numbers of at least two referees from previous places of employment that we may contact to seek references in connection with your suitability for the position to which this application relates.  Your referees will only be contacted if you are the preferred candidate.
REFEREE 1
REFEREE 2

AUTHORISATION TO TAKE PHOTOS FOR TRUST BUSINESS PURPOSESI hereby authorise the Trust to take photos of me and to use photos that I am in for the Trust business purposes only.  This may include photos taken during staff gatherings, staff identification cards, community events, Te Hiku Hauora website, promotional material, requests for photos for specific kaupapa, etc.  I acknowledge that the principles of the Privacy Act will be adhered to and the photos of me will not be shared outside of the Trust, e.g., they will not be shared with third parties.

AUTHORISATION TO TAKE PHOTOS FOR TRUST BUSINESS PURPOSES

PRIVACY ACT 1993
The information you have supplied on this application form, including the information in your CV, is to assess your suitability for employment with the Trust for the position applied for. Should we require evidence of your skills and experience you consent to produce such information, as necessary. Your information will be held securely in the Trusts Personnel files. No information will be disclosed to third parties without your authorisation, except as required by law. You have the right to access and request corrections to your personal information held by the Trust if there are incorrect details recorded.

DECLARATION:

By signing the declaration below, you acknowledge that you have read and understood the above statement and you are aware of your rights under the Privacy Act 1993, that you give authority to referees as stated, and that all information provided in this application is true and correct.  Failure to complete all sections of this application truthfully will render the application invalid, and should you have been successful in your application, can be grounds for dismissal.  Should you be offered employment with the Trust, this may be conditional on the successful outcome of a pre-employment medical examination by a registered medical practitioner (if required).

PLEASE UPLOAD YOUR CV 
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