Application for employment

"*" indicates required fields

Step 1 of 2 - Application Form

Application Form

NOTE: The completion of this form does not indicate that there is any obligation on the Company to engage the applicant.

CONFIDENTIAL

Date of application:*

Position Applied for:

How do you like to be addressed?

Given name:*

Christian Names:*

Are you known by any other name?*

Yes

Other name:*

Date of Birth*

Your contact details:

Contact Address*

Street Address * Address Line 2 * City * State / Province * ZIP / Postal Code * Country *

Contact Phone Number*

Email address*

Have you reached the current School leaving age?*

Yes

Have you qualified for National Superannuation?*

Yes

Section Break

Are you legally entitled to work in New Zealand?*

Yes

Education (Including University, further education etc. where applicable):

Name of Secondary School (s) attended:*

Qualifications (School certificate, University entrance- subjects):*

Apprenticeship (for fully qualified trade positions only)

Do you have your apprenticeship papers?*

Yes

What Trade were you apprenticed?*

Name and Address of the Employer?*

Qualifications:

Do you have any other qualifications/certificates/licenses or attended any courses (give details)?*

Describe the skills you hold which may be relevant to the position applied for:*

Employment History:

Present or most recent Employer:*

Company:*

Address:*

Job Held:*

Main Duties:*

Number of hours worked per week:*

Length of service:*

Reason for leaving:*

Do you have secondary employment?*

Yes

Please provide details

Referees

Give Name, Address and Telephone numbers of at least Two Referees:

If your application is accepted, how soon could you commence employment?*

I consent to the Company seeking verbal or written information about me from representatives of my previous Employers and/or referees and authorise the information sought to be released by them to the Company for the purposes of ascertaining my suitability for the position for which I am applying. I understand that the information received by the Company is supplied in confidence as evaluative material and will not be disclosed to me.

if yes to consent*

Yes

Date*

General

Are you prepared to work shifts if required to do so?*

Yes

Have you worked shifts before?*

Yes

Are you able to undertake work on nights or weekends if required?*

Yes

Are you able to travel for work, e.g. stay away from home overnight?*

Yes

Have you ever been convicted of a criminal offence?*

Yes

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

Yes

Are you prepared to handle all products or equipment used in the Industry?*

Yes

Do you have your own transport?*

Yes

Do you have a current driver’s license?*

Yes

What class?*

Are you a member of any Territorial Force Unit?*

Yes

have you completed whole time training?

What are your Interests/Hobbies/Sports/Clubs or Community Activities?

If you are offered employment, the offer is made subject to your obtaining a full medical clearance following the completion of our pre-employment medical.

Do you agree to undergo a medical examination including Drug and Alcohol testing?*

Yes

Do you consent to Biological Monitoring if applicable to the job?*

Yes

(Examples of this is exposure monitoring to loud noises, chemicals etc.)

Ensure Pre-employment Medical Form is Completed- (attached)*

Yes

Do you consent to the company retaining the information contained in this application form for the purpose of considering your suitability for any other position which may arise with this company in the future?*

Yes

Declaration:*

I declare

I declare that to the best of my knowledge the information
supplied in this application and any resume is correct and I understand that if any false or deliberately misleading information
is given or any material fact suppressed, I will not be accepted, or if I am employed, my employment will be terminated. I also
understand that any false information given in relation to my medical history with regard to gradual process, disease or
infection can result in my loss of entitlement for any compensation from ACC. I further understand that any offer of
employment if made is conditional on my obtaining a full medical clearance through the company’s pre-employment medical.
I consent to the company having access to and using the information arising from my pre-employment medical for the
purposes of confirming or declining my conditional offer of employment and authorise the information to be released to the
company.

Date:*

Your CV

Accepted file types: docx, pdf, , Max. file size: 25 MB.

Cover letter

Accepted file types: docx, pdf, Max. file size: 25 MB.

Confidential Health Record

Pre-Employment Medical Examination

Date

Given name:

Last name:

Address

Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of birth: (for identification purposes only)

Proposed occupation:*

Department:*

Availability*

Part time

Temp/Casual

Full time

Notice to applicants

This Information is collected and stored by Occupational Health Staff for Croft Pole Distributors. This form is a source of information which will be used by the Company to help it comply with the intention of the Health and Safety at Work Act 2015 (HSWA 2015) and the employee hereby consents to subsequent health monitoring.

If successful, the record will form part of your Occupational Health records. If unsuccessful, your record will be destroyed by Occupational Health Staff. The information contained is strictly confidential to Occupational Health Staff. However advice concerning fitness to work may be passed onto management without medical details.

Failure to supply the information requested would prejudice the Occupational Health Nurse/Medical Officer’s ability to assess your suitability for the position.

You have the right to request access to and correction of personal information in accordance with the Privacy Act 2020. Please apply to the HR Manager.

The above information is provided in accordance with the Privacy Act 2020.

Have you had long term exposure to:

Asbestos*

Yes

VDU (Visual Display Units – such as computer screens and projectors)*

Yes

Dust/Fumes etc*

Yes

Skin Irritants/Solvents*

Yes

Noise*

Yes

Lead*

Yes

Vibration e.g. driving*

Yes

Other chemicals*

Yes

Repetitive processes*

Yes

UV radiation*

Yes

If yes, give details

Company

Indicate job/exposures

Duration

Are you aware of any ill effects from any work you have done previously?

Effect details

Comments

Is there any reason why you would not be able to wear any of the following?

Breathing protection*

Yes

Comment

Ear plugs/Ear muffs*

Yes

Comment

Protective Gloves*

Yes

Comment

Safety boots/shoes*

Yes

Comment

Gumboots*

Yes

Comment

Safety Glasses*

Yes

Comment

Hard hat*

Yes

Comment

Personal Health History

Do you suffer from or have ever suffered from:

Epilepsy / convulsions / blackouts*

yes

Comment

Diabetes*

yes

comment

Respiratory problems / Asthma / bronchitis*

yes

comment

Hernia*

yes

comment

Gastric disorders*

yes

comment

Dermatitis / eczema / rashes / psoriasis*

yes

comment

Sleep disorders*

yes

comment

Allergies*

yes

comment

Dizziness at heights. Are you affected at all by working at height, on ladders or buildings?*

yes

comment

Claustrophobia. Are you affected by working in a confined space or below ground?*

yes

comment

High or low blood pressure*

yes

comment

Stress-related disorders*

yes

comment

Frequent headaches / migraine*

yes

comment

Heart disease / chest pain*

yes

comment

Serious illnesses / injuries*

yes

comment

Liver or kidney problems*

yes

comment

Have you a history of back injuries and or back problems?*

yes

comment

Have you had any broken bones?*

yes

comment

Have you had any joint problems that may affect ability to do the job?*

yes

comment

Do you have any restrictions on your mobility?*

yes

comment

Have you made any ACC claims?*

yes

comment

Have you had a history of gradual process injury / infection / disease?*

yes

comment

Have you had any mental illness or stress problems that could impact the safety of you or others at work?*

yes

comment

Are you aware of any condition, illness or injury that is likely to affect your ability to do the job in question?*

yes

comment

Are you presently unfit for work? I.e. Do you have a medical certificate?*

yes

comment

Do you wear a Medic Alert disc (or similar)?*

yes

comment

Current medication / drugs / injections which could possibly affect your performance or safety (impairment)?*

yes

comment

If the job involves working shift work, have you had previous shift work experience? Did you experience any health problems?*

yes

comment

Applicants Health Declaration

I agree to the contents of this record and confirm that it reflects a true record in regard to my past and present health. I have not withheld any relevant information that may affect my employment. I understand that should I be appointed, this record will be used as a base line to measure any future results of exposure to work hazards. I do not object to ACC or any insurer providing Croft Pole Distributors with a copy of any claims I have made in regard an injury or accident.

If you agree*

Yes

Date*

HR To Complete:

Pre-Employment Medical Assessment Completed:

Yes

Date

Drug Screening Result:

6 Pot Drug Screen: For Cannaboids, Opiates, Amphetamines, Cocaine and Benzodiazepines (AS/NZ S4308:2008 compliant to standard drug testing cup)

Result:

Cleared (negative)

Not cleared (non-negative, suspected sample

Fitness for employment deemed as:

Fit

Fit Fit with the following restrictions

Referred for additional medical review

UnFit

Comments: