Employment Application Form

Employment Application

Fill the form below accurately indicating your potentials and suitability to job applying for.
Name:*

First NameLast Name
Date of Birth*

DayMonthYear
Phone Number*

Area CodePhone Number
E-mail Address*
Address*

Street Address

Street Address Line 2

CityState / Province

Post CodeCountry
Drivers Licence Type*
Drivers Licence Number
Upload Photo ID - Drivers License (FRONT) or Passport

Upload a File

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Upload Photo ID - Drivers License (REVERSE)

Upload a File

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Criminal Convictions - Past or Pending*
Upload Police Vetting form*

Upload a File

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To download and complete Police Vetting form to upload click here. (Will open in new window.)
Work Entitlement
Work Entitlement - Please tick*

New Zealand CitizenPermanent ResidentHolder of a current work permitOther
If you are the holder of a work permit please provide details:
Type of Work Permit
Student / Open / Other - please state
Work Permit Number
Permit Expiry Date

DayMonthYear
Date
Number of hours permitted to work each week

:HourMinutes
Availability

Please tick or indicate hours available eg 7am – 2pm. Yes/No for Sleep/Wakeovers*

	Days	Nights	Sleepovers	Wakeovers
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

We use the Netsoft System which can use a mobile app to log in and out of shifts if you have a smart phone.
Do you have a smartphone?*

NoYes, AndroidYes, iOS (iPhone)Yes, Windows
First Aid
Do you have a current First Aid Certificate?*

YesNo
Expiry Date

DayMonthYear
Date
Job Skills & Training
Provide details of completed training / qualifications*
Upload training / qualifications

Upload a File

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What skills do you have?*

HouseworkMeal preparationChild CareShopping/errandsShowering female clientsShowering male clientsDressing/Undressing clientsHoist workPalliative CaresCatheter CaresBowel CaresExperience with pressure soresExp with Serious Spinal injury clientsExp with Brain injury clientsOther
What experience do you have?*

Nursing/Rest Home experienceGeneral hospital experienceTeachingEarly Childhood qualificationPrevious Support WorkCommunity NurseFoster ParentPersonal/Family Care experienceTertiary QualificationSocial WorkerMental HealthStudent NurseOther
Upload CV

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Health Questionnaire
Have you ever claimed ACC? (If yes please give details)
Are you currently receiving medical treatment and/or taking medication? (If yes please give details)
Is there any medical condition that could affect your ability to fulfill your obligations to our clients? (If yes please give details)
Past Employment
Present or Last Employer Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Post CodeCountry
Phone Number*

Area CodePhone Number
Position held*
Date commenced

DayMonthYear
Date finished

DayMonthYear
Duties / Responsibilites
Reason for leaving
Can we contact them?*

YesNo
References

Please list two (2) references that are familiar with your work life.
Reference 1
Name:*

First NameLast Name
Relationship*
E.g. Manager, Co-worker, Family member etc
Company
Phone Number*

Area CodePhone Number
Email Address
example@example.com
Reference 2
Name:*

First NameLast Name
Relationship*
E.g. Manager, Co-worker, Family member etc
Company
Phone Number*

Area CodePhone Number
Email Address
example@example.com
Head and shoulders photo
Please upload your head and shoulders photo here

Upload a File

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- References: your CV must provide at least two referees, with one being a current or previous employer that we have permission to contact. Please do not use a family member as a referee.
- We also complete a Police Check and a police vetting form must be completed
- Please include a recent head and shoulders photo for an Identification name badge to be made.
I have uploaded (please tick)

Photo IDCVPolice Vetting formHead and shoulders photo
Should be Empty: