Application For Employment Form Page 3


Have you or have you previously
Do you suffer from
An ACC Claim for any injury
Earache, deafness or ear discharge
Skin infections
Dermatitis or Eczema
High blood pressure
Heart complaint
Back injury or strain
Injury to limbs
Any allergies
Blackouts or seizures of any kind
Colour blindness
Are you taking drugs or medicine?
Mental problems or stress? i.e.
If yes, please give details
Depression or Anxiety?
Is there anything else we should know that may have an impact on your ability to perform any roles that
you are applying for?
Yes / No
Do you have a current Drivers licence?
Do you agree to provide a copy of your drivers licence if requested to do so?
Do you have secondary employment that you intend to continue if you are offered this position?
Can you work Shift work?
Are you prepared to work overtime?
Are you prepared to work as and where directed?
Are you prepared to abide by safety and work rules?
Have you been convicted of a criminal offence? If yes, give brief details
Are you awaiting the hearing of criminal charges? If yes, give brief details
Have you ever needed to take more than your sick leave allocation i.e. more than 5 days in 12
months? If yes, give brief details
Have you ever been dismissed, or resigned as an alternative to being dismissed in previous
Have you ever been subject to investigation for dishonesty or violence by a previous employer?
Have you ever submitted a personal grievance claim to an employer?
Declaration and acknowledgement:
This information is being collected to enable us to assess your suitability for this position and will be used for
this purpose only. If you fail or refuse to provide the information requested, then your application may be
rejected. If you provide false or inaccurate information, this will be considered serious misconduct and may
result in summary dismissal should you be employed by us. Please also note that any false information given
under the section “Medical” may result in your loss of entitlement to earnings related compensation.
The Privacy Act 1993 provides you with the right to request access to and/or correct the personal information
about you held by us.
I __________________________ (Full name) declare that to the best of my knowledge the information that I
have provided is accurate, and complete, and I have not withheld any information which may have a bearing
or any relevance to my application. I authorize Blue Sky Meats (NZ) Ltd, Morton Mains, RD1, Invercargill,
9871, to obtain personal information regarding my claims history from ACC.
Signature: ______________________________
Date: __________________________


00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Page of 3