Job Application Page

The information you provide on this application for employment will be collected and held by the Clutha District Council. This is collected for the purpose of assessing your suitability for employment by the Clutha District Council, which may include subsequent changes in employment within the Council, and to meet Council’s information requirements as a potential employer.

You have a right of access to personal information held by the Council and may seek correction of such information to ensure accuracy.

NOTE: All questions must be answered; either in the space provided in the following form, or in your accompanying curriculum vitae.

Please do not bind your CV or use a bulky presentation folder. A simple paper clip or staple is acceptable. CV’s will not be returned, so please do not include original documents.

Position applied for
How did you become aware of the vacancy?

Personal Information:
Family Name		First Name
Preferred name		Title
Residential Address		Telephone - Work Hours
Mailing Address		Telephone - After Hours
Email Address

Health and General Information:
1. Do you suffer from an illness/disability which would be aggravated or made worse by performing the job you have applied for?
2. Are you on medication that would affect your performance in the job that you have applied for?
3. Have you had an injury or medical condition caused by gradual process, disease, or infection - eg; hearing loss, sensitivity to chemicals, repetitive strain injury - which the tasks of this job may aggravate or contribute to?
If so, please give details on 1, 2 or 3 above.
Do you smoke?
Do you have a current drivers licence?
If yes, what class?
Are you waiting hearing of any charges for driving offences?
Have you been charged or convicted of a criminal offence? (This does not include convictions that are subject to the clean slate scheme of the Criminal Records (Clean Slate) Act 2004)
If yes, give brief details
Do you intend to engage in other paid work whilst employed in this position?
If yes, give brief details
Do you have any commitments which may prevent you from attending your place of employment during ordinary hours of work or affecting your availability for out of hours work?
If yes, give brief details
Are you legally entitled to work in New Zealand?
Are you prepared to abide by Health and Safety regulations?
Have you previously been employed by Clutha District Council
If yes, please give date of year last employed and name employed under
If your application is accepted, when could you commence employment?

Consents:
Do you agree to enquiries being made as to any other matters relating to your suitability for employment, and the accuracy of information, contained in this application?
Most recent employer		Comments
Past employer		Comments
Other persons		Comments

Referees:
Please give us details of referees that you authorise us to contact. Two work related and one personal.
1st work referee:
Name		Phone
Address		Occupation/Position
2nd work referee:
Name		Phone
Address		Occupation/Position
Personal referee:
Name		Phone
Address		Occupation/Position

Curriculum Vitae:
Please insert into the relevant sections below, details of your curriculum vitae [CV]. Please note that applications that do not include this
information will not be accepted.
EDUCATION:
Name of Educational Institutions attended (secondary and tertiary level only), qualifications or standard of achievement and year gained.

Details of relevant post qualification training:

Other qualifications or certificates you consider relevant showing dates obtained:

Membership of relevant professional associations and offices held:

EMPLOYMENT HISTORY:
Details of most recently held position, including employers name, address, position held, length of time in that position, number of staff
responsible for, position reported to and key tasks:

Details of other employment, starting with the most recent position, including employers name and address, position held and nature of work,
time in the position and reasons for leaving:

WORK EXPERIENCE RELEVANT TO POSITION:
Include job experience you consider would support your application for this position:

SPARE TIME INTERESTS AND EXPERIENCE:
Include details of general recreational and community activities you are involved in:

DECLARATION

I [your name] declare that to the best of my knowledge, the answers to the questions in this application are correct. I understand that if any false information is given or any material fact suppressed, I may not be accepted, or if I am employed, I may be dismissed.

Clutha District Council, PO Box 25, Balclutha