Fillable Printable PAK'nSAVE Application for Employment Form

PAK'nSAVE Application for Employment Form

UPPER HUTT

Application for Employment

THIS APPLICATION MUST BE RETURNED IN PERSON.

We will hold your personal information for a limited time. The information will be shared

with senior management personnel only. You may access this information at any time.

Position applied for__________________________________________ Today’s date _____________

Do you want full time or part time employment? (please circle one) Full Time Part Time

If part time, how many hours per week are you willing to work? _______________________________

Personal information

Full name: __________________________________________________________________________

Address: ___________________________________________________________________________

Contact phone number: _______________________ Male Female (please circle one)

Date of birth: __________________________

Are you a New Zealand Citizen/Resident YES NO (please circle)

If NO please advise visa expiry date ___________________ Attach copy of photo page of passport

Student Visa / Work Permit YES NO (please circle) Attach a copy of the

visa

Pak’N Save Upper Hutt’s hours of operation are from 7am – 11pm, 7 days a week.

(Please indicate your availability by placing a tick in the appropriate boxes below)

Day

MORNING

AFTERNOON

EVENING

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Education

Name of School/College/Polytechnic/University: FROM TO

________________________________________ ________ ________

Qualifications/Achievements/Trade Qualifications/Apprenticeship Details:

___________________________________________________________________________________

Employment history

1. Name of employer: ___________________________________________________________

Address: ____________________________________________________________________

Length of service: FROM: ____________________ TO: ______________________

Position held: ________________________________________________________________

Nature of work: ______________________________________________________________

Reason for leaving: ____________________________________________________________

2. Name of employer: ___________________________________________________________

Address: ____________________________________________________________________

Length of service: FROM: ____________________ TO: ______________________

Position held: ________________________________________________________________

Nature of work: ______________________________________________________________

Reason for leaving: ____________________________________________________________

Do you agree to inquiries being made as to the accuracy of information in this application form, or any other

matters relating to your suitability for employment? (please circle)

Present employer YES NO

Past employer YES NO

Other person YES NO

Please give details of referees whom you authorise us to contact:

1. Name of work related referee: ______________________________________________________

Address: ___________________________________________________________________________

Telephone number: ___________________________Relationship: ____________________________

2. Name of personal referee: __________________________________________________________

Address: ___________________________________________________________________________

Telephone number: ___________________________Relationship: ____________________________

General (please circle)

Are you a member of a territorial force unit or volunteer fire brigade? YES NO

Are you able to work shifts? YES NO

Are you able to work extra shifts? YES NO

Are you able to work weekends? YES NO

Are you able to work public holidays? YES NO

Are you currently engaged in other paid employment? YES NO

If YES, please provide details? __________________________________________________________

___________________________________________________________________________________

Will you remain employed with this other company while employed at PAK’nSAVE Upper Hutt?

YES NO

Have you ever been charged or convicted in a court in New Zealand or any other country within the last 7

years? You are not required to disclose any criminal offence protected by the Criminal records (clean slate)

Act 2004 YES NO

Are there any charges against you yet to be heard? YES NO

If YES, further information relevant to potential employment may be sought at any subsequent interview

If your application is accepted, when could you commence in this position? _____________________

Health (please circle)

Do you have any allergies substances or chemicals, which may be aggravated by working the position

applied for? ( For example: soap powders, flour dust, cleaning materials etc.) YES NO

Have you ever suffered any back injury or back strain, which may be aggravated by working the position

applied for? YES NO

Do you or have you ever suffered from any overuse injuries, which may be aggravated by working the

position applied for? (For example: RSI or OOS) YES NO

Have you ever made a claim under the ACC scheme? YES NO

If YES, please give details: __________________________________________________________

Do you have any other condition that may affect your ability to effectively carry out the functions and

responsibilities of the position applied for? YES NO

If so, please give details: ______________________________________________________________

___________________________________________________________________________________

Tasks related to positions at our store includes but are not exclusive of the duties below and may aggravate

any existing injuries:

Standing for long hours Climbing stairs/ladders

Writing and reading small print Operating machinery

Store work (dusty conditions) Customer service

Telephone answering Using a computer

Lifting goods onto shelves/tables from floor level

How many days absence due to sickness have you claimed in the last twelve months of employment?

(please circle one)

0 to 2 3 to 5 6 to 10 11 to-15 16 to 20 Over 20 days

Employment at Pak’N Save Upper Hutt will be terminated without further notice if an employee posses,

brings, uses, consumes, supplies or process unlawful drugs or intoxicating liquors (except as prescribed by a

registered medical practitioner) on Company premises without authorisation, or while wearing the Company

uniform. When an employee is suspected to have been party to the consumption of any drug or alcohol

product as described above, that person will make themselves available for any tests or any other means

deemed necessary to establish the truth thereof.

Additional Information

Do you know any staff member that have worked or work for Pak’nSave Upper Hutt? YES NO

If you answered yes name of current or past employee ______________________________________

Is there any other information that we should be aware of that may impact on your ability to perform a role

within this Supermarket? YES NO

If so, please give details: ______________________________________________________________

___________________________________________________________________________________

Declaration

________________________________ (full name) declare that to the best of my knowledge, the answers

to the questions in this application are correct. I understand that if any false information is given, or any

material fact suppressed, I may not be accepted, or if I am employed, I may be dismissed. I also understand

that any false information given in section 5, the medical portion of this form, may result in my loss of

entitlement for any compensation from ACC.

Signature: ______________________________________________ Date: ____________________

ALL APPLICANTS MUST HAVE AN IRD NUMBER BEFORE YOU WILL BE

CONSIDERED FOR EMPLOYMENT