Pre-employment application form


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NamePre-employment application form
A typeDocumentation








PRE-EMPLOYMENT APPLICATION FORM

Name




Address




PHONE Home

Mobile




Work




Date of Birth (OPTIONAL)




PLACES OF EDUCATION

Primary




Secondary




Polytech/Tertiary




QUALIFICATIONS

(Eg. School Cert)





Interests/Hobbies










Do you hold a current Driver’s License Yes  No 

Are you a New Zealand Resident Yes  No 

If NO, what entitlement do you have to work in New Zealand? (copy of evidence to work provided)


Last Place of Employment







Start Date




Finish Date




Reason For Finishing









PREVIOUS WORK HISTORY

EMPLOYER

START & FINISH DATES

POSITION HELD

REASON FOR LEAVING





































Referees

1)

2)

3)


Reason for wanting to work at Kiwi Lumber:




DECLARATION OF HEALTH STATUS

General Questions


Do you have any health problems that may:

Affect your ability to perform your intended job?

Be affected by your intended work?

Affect the health of other workers?

If you answered yes to any of these questions please provide the full details:




Yes  No 

Yes  No 

Yes  No 


Are you taking any medication which may affect your ability to carry out the duties required for this position?

If yes, provide details:




Yes  No 



Have you had any work related injury or illness that may affect your ability to do the job you have applied for?

If yes, provide details:




Yes  No 



Have you previously made an ACC claim for an injury or illness that could be aggravated by the type of work you are applying for?

If yes, please provide details:




Yes  No 

Work in Noisy Environment





When did you last have your hearing tested?

Date:

Do you have problems with your hearing such as being unable to hear or a ringing in your ears?

If yes, please provide details:




Yes  No 


Have you worked in noisy environments in the past?

If yes, please provide details:




Yes  No 





Wearing Personal Protective Equipment




Is there any reason you would not be able to wear the following:

Steel capped safety boots

Ear protection

Safety glasses

Hard Hat

Breathing apparatus or mask

Protective Overalls

Gloves

If yes, please provide details:




Yes  No 

Yes  No 

Yes  No 

Yes  No 

Yes  No 

Yes  No 

Yes  No 

Repetitive Motions with Upper Limbs





Have you ever had a gradual process injury that may be aggravated by the job you are applying for, e.g. occupational overuse syndrome/repetitive strain injury?

If yes, please specify:



Yes  No 


Do you have any pain, stiffness, weakness, past injury or arthritis affecting the use of the following:

Hands/wrists

Arms/shoulders

Neck/lower back

If you answered yes to any of the above please describe:





Yes  No 

Yes  No 

Yes  No 

Working with Chemicals / Working with Grease and Solvents





Do you have a history of:

Excema

Any skin condition affecting your hands

Asthma

If you answered yes to any of the above please describe:




Yes  No 

Yes  No 

Yes  No 


Manual Lifting, pushing or pulling heavy weights / Climbing up and down stairs / Working with or on vibrating equipment / Standing for prolonged periods / Sitting for prolonged periods




Do you have any arthritis, stiffness, pain, pins and needles or injury affecting the use of the following parts of your body:

Hands/wrists

Arms/shoulders

Neck

Back

Hips/knees

Feet

Have you ever had a back injury or operation

If you have answered yes to any of the above questions please provide details:





Yes  No 

Yes  No 

Yes  No 

Yes  No 

Yes  No 

Yes  No 

Yes  No 

Operating Heavy machinery / Working at heights / Driving





Have you ever had epilepsy or a seizure/fit

Have you had an episode of loss of consciousness

Do you take any medication that may affect your ability to concentrate

Do you have diabetes

Do you have any known heart problem

If you answered yes to any of the above questions please describe:


Yes  No 

Yes  No 

Yes  No 

Yes  No 

Yes  No 

Working in a dusty environment





Have you had any of the following problems in the past 3 months:

Wheezing in the chest

Coughing at night

Shortness of breath when walking at normal pace

Have you ever suffered from asthma

If yes, have you, in the past 12 months:

Taken steriod/prednisone treatment

Seen a doctor for your asthma

Been admitted to hospital

If you answered yes to any of the above please describe:




Yes  No 

Yes  No 

Yes  No 

Yes  No 
Yes  No 

Yes  No 

Yes  No 

Over the past twelve months, have you been taking any prescribed drugs or medicines?

If yes, what were they for:



Yes  No 

Have you spent time in hospital or outpatients over the last twelve months?

If yes, what was your ailment?



Yes  No 

MEDICAL TESTING

If requested, do you agree to undergo a medical examination?

Yes  No 

Do you consent to any biological monitoring if applicable to the Job? (For example, testing for exposure to chemicals used on site)

How many days absence were claimed due to sickness in your last 12 months of employment?

0-5 6-10 11-15 over 16 days

Yes  No 


Are there any personal circumstances known to you that would affect your ability to perform your duties on a full time basis?

If yes, please provide details:


Yes  No 

OTHER DETAILS

Have you in the last ten years been convicted of any criminal offence?

Yes  No 

If yes, please provide details of conviction/s:


Do you agree to play a vital and responsible role in maintaining a safe and

healthy workplace by observing all safe work procedures, rules and instruction? Yes  No 
Have you ever had a verbal or written warning or been dismissed from a role

as a result of a health and safety issue? Yes  No 


Are you able to work night shift/overtime?

Yes  No 



APPLICANT’S AUTHORITY TO RELEASE INFORMATION TO A THIRD PARTY

Please release to the undersigned:

Full name of third party: Kiwi Lumber

Address of third party:

DECLARATION


I, (full name) declare that to the best of my knowledge the answers to the questions in this application are correct and 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.

I authorise you or your agent to contact any previous employers and the referees listed in this application and obtain information from them to be used in relation to my application for employment for the purposes of ascertaining my suitability for the position I am applying for. If the named referee or supervisor supplied is not authorised to speak on behalf of the company, or if not available, enquiries can be made with the Manager or other duly authorised person.

I further authorise you to furnish any third party such details from this application as you reasonably require in order to make the enquiries, or credit check request as authorised above.

I understand that the information received by the company is supplied in confidence as evaluative material and will not be disclosed to me.

I have read and fully understand this Declaration.



Witness’ Signature:

____________________________________
Applicant’s Signature:

____________________________________



Date:

________________________
Date:

________________________





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