Application For Employment Form (Page 3 of 3) in pdf

Have you or have you previously

Yes

When

Do you suffer from

Yes

had

An ACC Claim for any injury

Earache, deafness or ear discharge

Skin infections

Dermatitis or Eczema

High blood pressure

Hernia

Heart complaint

Back injury or strain

Diabetes

Injury to limbs

Any allergies

Blackouts or seizures of any kind

Colour blindness

Are you taking drugs or medicine?

OOS

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

General

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

employment?

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: __________________________

Application For Employment Form Page 3

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