Account | Counties Manukau Homecare Trust

Name:

Ethnicity: NZ/European Maori Pacific Islander European/Other Asian/Indian

Required for statistical purposes

Contact:

Emergency Contact:

Legal Work Status: Do you need a work permit to work in New Zealand?* Yes No

Qualifications:

Present or Most Recent Employer:

Start Date*:

End Date*:

Next Most Recent Employer:

Start Date*:

End Date*:

Next Most Recent Employer:

Start Date*:

End Date*:

Other Information:

Referee One:

Referee Two:

General: Are you prepared to work on weekdays?*

Yes No

Are you prepared to work during School Holidays?*

Yes No

Are you prepared to work during weekends?*

Yes No

Are you prepared to work during evenings?*

Yes No

Have you been convicted of a criminal offence?*

Yes No

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

Yes No

(if yes for either of the two questions above, further Relevant information may be sought at the time of Interview)

Do you have your own transport?*

Yes No

Do you have a current full NZ driver's licence?*

Yes No

I understand I will undertake all responsibilities as outlined in the job description*

Yes No

I understand that I will be required to undertake NZQA Community Support Service training as part of my orientation*

Yes No

I understand attending in-service and any other training as required, is mandatory*

Yes No

Have you had an injury or medical condition caused by gradual process, disease or infection (e.g. back injury or strain, asthma, stress-related conditions, occupational overuse syndrome, sensitivity to chemicals), that may be aggravated or further contributed to, by the tasks of this job or prevent you from carrying out your responsibilities?*

Yes No

Do you consent to Counties Manukau Homecare Trust retaining the information contained in this application form for the purposes of considering your suitability for any other position which may arise with Counties Manukau Homecare Trust in the future*

Yes No

I declare that to the best of my knowledge the information supplied in this application and in any resume provided 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 regards to gradual process, disease or infection can result in my loss of entitlement for any compensation from the Workplace Insurer*

Yes No

I consent to Counties Manukau Homecare Trust seeking verbal or written information about me from referees on a confidential basis. I authorise the referees to release this information to Counties Manukau Homecare Trust to assess my suitability for the position for which I am applying for. I understand that the information received by Counties Manukau Homecare Trust is provided in confidence as evaluative material and will not be disclosed to me if the referee has not given consent to their reference*

Yes No

Day	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday	Public Holidays
MORNING TIMES - From 6.30 am to 12 pm
Start
End
AFTERNOON TIMES - From 12 pm to 5 pm
Start
End
EVENING TIMES - From 5 pm to 8 pm
Start
End

Application for Support Worker Employment