EMPLOYMENT APPLICATION
CONFIDENTIAL
Date of application____________________________
This application must be completed personally by the Applicant in your own handwriting.
APPLICATION FOR EMPLOYMENT
Applicants please note:
The completion of this form does not indicate that there is any obligation on this Company to engage the applicant. You should provide complete information for each question unless otherwise advised, regardless of whether you consider it relevant to the position for which you have applied. Failure to complete this form in the manner required may result in your application being declined. Please ensure that you read and complete this application form thoroughly.
PURPOSE
This information is collected for the purpose of assessing your suitability for employment at
Handy Rentals Ltd, which may include subsequent changes in employment with the company. We wish to retain the information on file.
Permission granted / not granted. (Strike one out please)
Please print
Initial position applied for: ________________________________________________
Your name Mr/Mrs/Miss/Ms
(In block letters)
Surname: _______________________________________________________
Given Names (underline names used) ____________________________________
_______________________________________________________
Are you known by any other name(s)? ___________________________________
Give details: _______________________________________________________
Your Home Number & Street: ____________________________
Address Suburb & Town: ______________________________
& Telephone Contact phone No: ___________________________
Email _______________________________________________
Do you have the legal rights to work in New Zealand, either permanent residence or under a valid work permit? (Evidence may be required if you are interviewed for the position).
Yes/No
Education Name of secondary school(s) attended and number of years attended:
(Including _________________________________________________________________________
University, _________________________________________________________________________
further _________________________________________________________________________
education _________________________________________________________________________
etc. where _________________________________________________________________________
applicable) _________________________________________________________________________
Qualifications (School Certificate, University Entrance) subjects:
_________________________________________________________________________
_________________________________________________________________________
Other Qualifications
Yes/No
Subjects:
_________________________________________________________________________
_________________________________________________________________________
Languages
Can you speak any other language other than English?
Yes/No
Language(s)________________________________________________________________________
Please describe the skills you hold which are relevant to the position applied for. (e.g. for a typist – typing speed, word processing capability, shorthand capability, etc.)
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Employment History
Present or Most Recent Employer
From to
Company: _________________________________________________
Address _________________________________________________
Job held: _________________________________________________
Main Duties: _________________________________________________
_________________________________________________
No. of hours worked per week: _________________________________________________
Reason for leaving: _________________________________________________
For the purposes of compliance with the Privacy Act 1993 do you consent to the company contacting your present employer for the purposes of reference checking?
Yes / No
Next Most Recent Employer
From to
Company: _________________________________________________
Address _________________________________________________
Job held: _________________________________________________
Main Duties: _________________________________________________
_________________________________________________
No. of hours worked per week: _________________________________________________
Reason for leaving: _________________________________________________
Next Most Recent Employer
From to
Company: _________________________________________________
Address _________________________________________________
Job held: _________________________________________________
Main Duties: _________________________________________________
_________________________________________________
No. of hours worked per week: _________________________________________________
Reason for leaving: _________________________________________________
_________________________________________________
_________________________________________________
Give details of any other job which may be relevant: _______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Have you ever worked for this company before?
Yes / No
If yes, where and when? _______________________________________________________
Do you have secondary employment?
Yes / No
If yes, please give details: ______________________________________________________
Referees
Give name, address and telephone numbers of at least two referees. (Preferably from where you have worked)
Name Position Address Phone No.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
If your application is accepted, when could you commence employment?
_____________________________________
I consent to Handy Rentals seeking verbal or written information about me from representatives of my previous employers and/or referees and authorise the information sought, to be released to Handy Rentals.
Yes/No If yes: _______________________________ Signature. Date: _______________
General
Are you prepared to work overtime if required? Yes/No
Have you been convicted of a criminal offence? Yes/No
Are you awaiting the hearing of charges in a civil or criminal court of law? Yes/No
Are you prepared to handle all products, materials or equipment used in this industry?
Yes/No
Do you have a current drivers licence? Yes/No
If yes, what class? ____________________________________________________________________
Drivers Licence number: _______________________________________________________________
Do you have any demerit points or endorsements? Yes/No
If yes, please detail: ___________________________________________________________________
Occupation of spouse / partner: _________________________________________________________
What transport arrangements do you have to attend your place of employment? ___________________
Are you a member of any territorial force unit? Yes/No
If so, have you completed whole time training? Yes/No
Do you have or are you aware of any likely commitments which may prevent you from attending your place of employment during normal work hours or effect your availability for overtime or employment related travel (e.g. Sports, hobbies, special interests, education, training, etc)? ___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Medical
Do you smoke? Yes/No
Do you agree to undergo a medical examination if required? Yes/No
Are you allergic to, or have any sensitivity to any substances or chemicals? Yes/No
Do you require corrective lenses or contact lenses? Yes/No
Have you ever suffered from a back injury requiring time off work? Yes/No
State any serious injury or illness you have suffered that may affect your ability to effectively carry out the functions and responsibilities of the position applied for:
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Do you know of any other condition, which may affect your ability to effectively carry out the functions and responsibilities of the position applied for? Yes/No
If yes, please detail:
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Do you know of any other condition, which might put customers or staff at risk? Yes/No
If yes, please detail:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
________________________________________________________________
In your past employment have you been exposed to:
Noise Yes/No
Asbestos Yes/No
Heavy metals Yes/No
Solvents Yes/No
Skin irritants Yes/No
Infectious material Yes/No
If yes, please detail
_________________________________________________________________________________________________________________
Do you consent to Handy Rentals retaining the information contained in this application form for the purposes of considering your suitability for any other position, which may arise with this company in the future? Yes / No
Declaration
I (Full Name) _____________________________________declare that to the best of my knowledge the answers in this application are correct and I understand that if any false or deliberately misleading information is given, or any material fact suppressed, I will not be accepted, or if I am employed, I may be dismissed.
Signed: _________________________________ Date:______________________
COMPANY EMPLOYMENT CRITERIA
1. All customers are to be treated in a manner that will ensure they will want to introduce their friends and relatives. This is really the only affordable advertising and is critical to the immediate success of this business.
2. You will be required to work for (40) hours per week.
3. As well as your main duties, you will be required to carry out administrative and cleaning tasks as required.
4. The principals of the company are to be advised of any changes to policy staff wish to make or of any suggestions or complaints.
5. Any information made available to staff is to be treated in total confidence. Management feels this is to be very important and any transgression would be treated as grounds for dismissal.
6. It is required that prior approval is sought before any changes are made to normal working hours.
Signed: _________________________________Date_______________________
Infringement example form
The following are examples of behaviour that may lead to a warning that your employment is in jeopardy.
1. Failure to perform work to the required standard.
2. Poor time keeping.
3. Insubordination.
4. Using bad or abusive language at work.
5. Leaving your work position without authority.
6. Failure to follow reporting procedures as laid down in the Employment Agreement.
7. Failure to follow other workplace procedures as laid down in the Employment Agreement.
8. Using the telephone for personal calls without authority.
9. Negligence
10. Breach of company policies.
11. Or any other matter considered by the employer to justify a warning.
The following are examples of behaviour that may lead to dismissal.
1. Serious negligence.
2. Refusing to reveal the contents of a bag or locker when requested.
3. Serious breach of this company’s Safety and Health requirements.
4. Horse-play or fighting at work.
5. Unauthorised possession of company or other employee’s property (note: any procedures for obtaining company property, whether borrowing equipment or purchasing from the company, should be detailed to all staff, and care should be taken to ensure that the procedures are understood).
6. Discrimination (Harassing a co-worker or visitor).
7. Possessing drugs or alcohol at work without good cause or without authority.
8. Consuming or being under the influence of drugs or alcohol without authority, except when the drug is used in accordance with a prescription by a doctor.
9. Failure to follow cash-handling procedures.
10. Unauthorised use of company equipment or vehicles.
11. Falsification of company records.
12. Damage of property.
13. Misuse of confidential information and/or removal or copying of confidential information or any other matter considered by the employer to justify dismissal.
14. Lying.
15. Serious breach of company policies.
EXPLANATION OF GRADUAL PROCESS INJURY QUESTIONAIRE
This company is trying to ascertain the risk of aggravating an existing medical condition, or causing any gradual process injury, disease or infection through the tasks you will be required to perform if you are appointed to the position you are applying for.
The tasks involved in the position applied for include (both repetitive hand movements and prolonged muscle tension)(exposure to a noise hazard )and therefore will unreasonably expose anyone with a pre-existing (gradual process injury)(hearing loss)to aggravate the condition.
If you are appointed, the information you provide will indicated how frequently we need to monitor your health and your exposure to any minimized significant hazard through those tasks. The information will also assist us in preventing you from attracting any gradual process injury.
Please answer the following questions. It is important the questions are answered truthfully and accurately.
Any false or deliberately misleading information that is given, or any material fact suppressed, will disqualify you from employment with Handy Rentals. If you are employed, such false and misleading information will be grounds for dismissal.
I have read and fully understand the above.
Applicant’s Name: ____________________________________
Applicant’s Signature: ____________________________________
GRADUAL PROCESS INJURY, INFECTION OR DISEASE
(PRE-EMPLOYMENT QUESTIONAIRE)
1. Have you ever had, or do you currently have, any medical condition caused by gradual process injury, disease or infection? Yes/No
(e.g. Occupational Overuse Syndrome, Repetitive Strain Injury, Occupational Hearing Loss, Sensitivity to chemicals).
If yes, please indicate if it was diagnosed as any of the following:
Tendonitis ______________________
Tenosynovitis ______________________
Carpal Tunnel Syndrome ______________________
Ligament Sprain ______________________
Medial Epicondylitis ______________________
Lateral Epicondylitis ______________________
Other: ______________________
If yes, please describe the symptoms:
_____________________________________________________________________________________
2. Have you ever received treatment for a gradual process injury, disease or infection?
Yes/No
Date treatment started _____________________
Date treatment finished _____________________
Still under treatment? Yes/No
Please name the medical profession who treated you: ________________________________
Address of medical centre or surgery: ________________________________________________
Comments:
_________________________________________________________________________________________
__________________________________________________________________________________________
____________________________________________________________________________
3. Have you ever experienced any of the following overuse injury symptoms?
Pain and weakness Yes/No
Pins and needles Yes/No
Burning or cold sensation Yes/No
Muscle discomfort Yes/No
Fatigue Yes/No
Numbness Yes/No
If yes, please describe the symptoms:
___________________________________________________________________________________________
____________________________________________________________________________________________
________________________________________________________________________
4. Please describe your recreational and domestic activities or hobbies. (E.g. sports, musical instruments, gardening, etc)
____________________________________________________________________________________________
__________________________________________________________________
5. Are you aware of any pre-existing medical condition that is either due to work related or non- work related activities? Please describe:
___________________________________________________________________________________________
___________________________________________________________________
6. Have you ever had a claim for OOS/RSI for compensation from the ACC?
Yes/No
If yes please give details:
_________________________________________________________________________________________
_____________________________________________________________________
7. Is there any family history of Fibromyalgia? (Chronic Fatigue Syndrome)
Yes/No
If yes, please describe:
_________________________________________________________________________________________
_____________________________________________________________________
8. During previous employment have you ever been exposed to OOS or any other gradual process injury, disease or infection through the tasks you have had to perform?
Yes/No
If yes, please describe the tasks and exposure:
_____________________________________________________________________________________
______________________________________________________________________________________
____________________________________________________________________________________
9. Have you used a computer in previous employment? Yes/No
If yes, how many hours a day did you use the computer?_______________________________
Have you any formal certificates or qualifications in computer use? Yes/No
If yes, please describe the qualifications:
_______________________________________________________________________________________
___________________________________________________________________________________
10. How many words per minute can you type? __________________________________________
Private use of computers
Do you have a computer at home? Yes/No
If yes:
How many hours a week do you spend using the computer? _________
Are you on the internet? Yes/No
Do you ever use a mouse? Yes/No
Have you ever had any formal training in OOS prevention? Yes/No
If yes, please complete the following:
When was the training completed? ________________________
Who ran the training session? ________________________
Did the training cover Causes? Yes/No
Preventive measures? Yes/No
Monitoring? Yes/No
Workstation set-up? Yes/No
Briefly describe your understanding of the causes of OOS/RSI:
___________________________________________________________________________
___________________________________________________________________________
Applicants name: ______________________________________________________
Applicants signature: ______________________________________________________
Date: ______________________________________________________