The Health and Disability Commissioner

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COLLECTING AND HOLDING PERSONAL INFORMATION:
The information you provide on this form for employment will be collected and held by the Health and Disability Commissioner.

PURPOSE:
This information is collected for the purpose of assessing your suitability for employment with the Health and Disability Commissioner which may include subsequent changes in employment within the office of the Health and Disability Commissioner.

YOUR ACCESS TO THIS INFORMATION:
You have a right of access to personal information and to seek any correction you think necessary to ensure accuracy.

POSITION APPLIED FOR: Employment with the Health and Disability Commissioner for the position of

Note: In order for us to consider your application you should provide complete information in answer to each question unless otherwise advised, regardless of whether you consider it relevant to the position applied for.

Information given in Sections 1 – 3 can be repeated and expanded in your CV, which you must attach at Section 7 of this form.

Section 1 - Personal information

First Name(s)

Last Name

If you are known by any other names please record them here:

Address

Home phone

Business phone

Mobile phone

Email address

Section 2 - Education (including university, further education etc)

Name of School/College/Polytechnic/University, Qualification (from/to), Standard of Achievement/Accomplishment

Skills and Experience (regardless of formal qualifications)

Section 3 - Employment history (start with the most recent position)

Name of employer, Length of service (from/to), Position held, Nature of work, Reason for leaving

Have you previously been employed by the Health and Disability Commissioner?

Yes

Do you agree to enquiries being made as to the accuracy of information contained in this application form or any other matter relating to your suitability for employment?

Present employer:

Yes

Past employer:

Yes

Other person:

Yes

Please give details of at least two direct line managers as referees who you authorise us to contact, one of which must be your current/last direct line manager.

Name, Email address, Phone Number, Occupation/Position held

Section 4 - General

Do you intend to engage in other paid work whilst employed in this position?

Yes

If yes, give brief details:

Have you been charged with or convicted of a criminal offence in the last 10 years (other than a conviction that you are lawfully entitled to withhold under the Criminal Records (Clean Slate) Act 2004)?

Yes

As part of our employment process, all candidates for employment with HDC will undertake a Criminal Conviction check, and appointment is subject to a satisfactory outcome. Do you give your consent to this check?

Yes

Do you consent to the disclosure to HDC of whether you have been subject to a serious misconduct investigation, either concluded and upheld or currently under investigation, from all previous Public Service and statutory Crown entity employers for the last three years? This will usually be conducted at the preferred candidate stage.

Yes, I consent

No, I do not consent

I would like to discuss this before it is undertaken

If yes, give brief details:

Are you aware of any possible conflict of interest that may arise, if you were to be offered, and accept, employment with HDC?

Yes

If yes, give brief details:

If your application is accepted when you could you start employment?

What are your salary expectations for this position?

Are you legally entitled to work in New Zealand?

Yes

Where did you see the role advertised?

HDC website

Seek

Government jobs online

Other

If other (please state):

Section 5 - Medical

Do you have any health related condition which may affect your ability to effectively carry out the functions and responsibilities of the position applied for? If so, please give details:

Section 6 - Additional information

Do you have any additional information, which you would consider may assist your application. For example, achievements, interests, aspirations etc. If so, please list below or attach any additional information to this application form.

Section 7 - Attachments

Please attach your CV

Please attach your cover letter

Please attach any other documents

Section 8 - Declaration

By submitting this form I declare that to the best of my knowledge, the answers to the questions in this application are correct. I understand that if any false or misleading information is given, or any material fact suppressed, I may not be accepted, or if I am employed, I may be dismissed. I consent to HDC seeking verbal or written information on a confidential basis about me from my referees and authorise the information sought to be released by them to HDC for the purposes of ascertaining my suitability for the position for which I am applying. I understand that the information received by HDC is supplied in confidence as evaluative material and will not be disclosed to me.

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Confidential - Application for employment

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Section 1 - Personal information

Section 2 - Education (including university, further education etc)

Section 3 - Employment history (start with the most recent position)

Section 4 - General

Section 5 - Medical

Section 6 - Additional information

Section 7 - Attachments

Section 8 - Declaration

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