Application for employment "*" indicates required fields Step 1 of 2 - Application Form 0% Application FormNOTE: The completion of this form does not indicate that there is any obligation on the Company to engage the applicant. CONFIDENTIAL Date of application:* DD slash MM slash YYYY Position Applied for: How do you like to be addressed? Given name:*Christian Names:*Are you known by any other name?* Yes No Other name:*Date of Birth* DD slash MM slash YYYY Your contact details:Contact Address* Street Address * Address Line 2 * City * State / Province * ZIP / Postal Code * AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country * Contact Phone Number*Email address* Have you reached the current School leaving age?* Yes No Have you qualified for National Superannuation?* Yes No Section BreakAre you legally entitled to work in New Zealand?* Yes No 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 No 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 No Please provide detailsRefereesGive 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 No Date* DD slash MM slash YYYY GeneralAre you prepared to work shifts if required to do so?* Yes No Have you worked shifts before?* Yes No Are you able to undertake work on nights or weekends if required?* Yes No Are you able to travel for work, e.g. stay away from home overnight?* Yes No Have you ever been convicted of a criminal offence?* Yes No Are you awaiting the hearing of charges in a civil or criminal law court?* Yes No Are you prepared to handle all products or equipment used in the Industry?* Yes No Do you have your own transport?* Yes No Do you have a current driver’s license?* Yes No What class?*Are you a member of any Territorial Force Unit?* Yes No 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 No Do you consent to Biological Monitoring if applicable to the job?* Yes No (Examples of this is exposure monitoring to loud noises, chemicals etc.)Ensure Pre-employment Medical Form is Completed- (attached)* Yes No 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 No Declaration:* I declareI 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:* DD slash MM slash YYYY Your CVAccepted file types: docx, pdf, , Max. file size: 25 MB.Cover letterAccepted file types: docx, pdf, Max. file size: 25 MB. Confidential Health RecordPre-Employment Medical ExaminationDate DD slash MM slash YYYY Given name:Last name:Address Same as previous Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of birth: (for identification purposes only) DD slash MM slash YYYY 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 No VDU (Visual Display Units – such as computer screens and projectors)* Yes No Dust/Fumes etc* Yes No Skin Irritants/Solvents* Yes No Noise* Yes No Lead* Yes No Vibration e.g. driving* Yes No Other chemicals* Yes No Repetitive processes* Yes No UV radiation* Yes No If yes, give detailsCompanyIndicate job/exposuresDuration Are you aware of any ill effects from any work you have done previously? Effect details Add RemoveComments Add RemoveIs there any reason why you would not be able to wear any of the following?Breathing protection* Yes No CommentEar plugs/Ear muffs* Yes No CommentProtective Gloves* Yes No CommentSafety boots/shoes* Yes No CommentGumboots* Yes No CommentSafety Glasses* Yes No CommentHard hat* Yes No CommentPersonal Health HistoryDo you suffer from or have ever suffered from:Epilepsy / convulsions / blackouts* yes No CommentDiabetes* yes No commentRespiratory problems / Asthma / bronchitis* yes No commentHernia* yes No commentGastric disorders* yes No commentDermatitis / eczema / rashes / psoriasis* yes No commentSleep disorders* yes No commentAllergies* yes No commentDizziness at heights. Are you affected at all by working at height, on ladders or buildings?* yes No commentClaustrophobia. Are you affected by working in a confined space or below ground?* yes No commentHigh or low blood pressure* yes No commentStress-related disorders* yes No commentFrequent headaches / migraine* yes No commentHeart disease / chest pain* yes No commentSerious illnesses / injuries* yes No commentLiver or kidney problems* yes No commentHave you a history of back injuries and or back problems?* yes No commentHave you had any broken bones?* yes No commentHave you had any joint problems that may affect ability to do the job?* yes No commentDo you have any restrictions on your mobility?* yes No commentHave you made any ACC claims?* yes No commentHave you had a history of gradual process injury / infection / disease?* yes No commentHave you had any mental illness or stress problems that could impact the safety of you or others at work?* yes No commentAre you aware of any condition, illness or injury that is likely to affect your ability to do the job in question?* yes No commentAre you presently unfit for work? I.e. Do you have a medical certificate?* yes No commentDo you wear a Medic Alert disc (or similar)?* yes No commentCurrent medication / drugs / injections which could possibly affect your performance or safety (impairment)?* yes No commentIf the job involves working shift work, have you had previous shift work experience? Did you experience any health problems?* yes No commentApplicants 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 No Date* DD slash MM slash YYYY This field is hidden when viewing the formHR To Complete:This field is hidden when viewing the formPre-Employment Medical Assessment Completed: Yes No This field is hidden when viewing the formDate DD slash MM slash YYYY Drug Screening Result:6 Pot Drug Screen: For Cannaboids, Opiates, Amphetamines, Cocaine and Benzodiazepines (AS/NZ S4308:2008 compliant to standard drug testing cup)This field is hidden when viewing the formResult: Cleared (negative) Not cleared (non-negative, suspected sample This field is hidden when viewing the formFitness for employment deemed as: Fit Fit Fit with the following restrictions Referred for additional medical review UnFit This field is hidden when viewing the formComments:
