Fillable Printable PAK'nSAVE Employment Application Form
Fillable Printable PAK'nSAVE Employment Application Form
PAK'nSAVE Employment Application Form
1
KILBIRNIE
CONFIDENTIAL
EMPLOYMENT APPLICATION FORM
SECTION 1 – PERSONAL INFORMATION
(Please Print)
First name(s):________________________________________ Family (Surname): ______________________________________
If you are known by any other names please record here: __________________________________________________________
Residential Address: _________________________________________________________________________________________
Telephone Number: _______________________________ Date of birth: __________________ IRD Number:_______________
(If under 18yrs)
Mobile Phone Number: ____________________________ Email: ________________________________________________
SECTION 2 – EDUCATION
Name of education organisations (e.g. Secondary School attended and highest qualifications or Unit Standards achieved)
Qualifications (including Trades) / Polytechnic, University, Private Training Establishments
(Including Secondary & Tertiary and length of time attended)
Training Establishment Qualifications Standards Achieved Year of Attendance
Secondary School EG: NCEA Level 1
Do you have any other qualifications/certificates, or have you attended any courses relevant to the position?
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
SECTION 3 – PREFERRED DAYS OF WORK AND HOURS OF WORK
Please state your preferred Department and/or Position you are interested in: Full Time / Part Time
Preferred Department: 1.___________________________ 2.____________________________ 3.________________________
Day Start times Finishing time
MONDAY am/pm am/pm
TUESDAY am/pm am/pm
WEDNESDAY am/pm am/pm
THURSDAY am/pm am/pm
FRIDAY am/pm am/pm
SATURDAY am/pm am/pm
SUNDAY am/pm am/pm
Please note all Employees are required to work one day in the weekend
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SECTION 4 – EMPLOYMENT HISTORY AND REFEREES
Have you previously been employed by Foodstuffs, New World, Pak’nSave, 4 Square, or in this industry? Yes: No:
Please list your most recent employer first.
Current Employer: ___________________________________________City: _____________________________
Length of Employment: From ____/____/____ to ____/____/____ Position Held: _____________________________
Nature of Work: ____________________________________________________________________________________________
Reason for Leaving: __________________________________________________________________________________________
Name of Company: ___________________________________________City: _____________________________
Length of Employment: From ____/____/____ to ____/____/____ Position Held: _____________________________
Nature of Work: ____________________________________________________________________________________________
Reason for Leaving: __________________________________________________________________________________________
Name of Company: ___________________________________________
City: _____________________________
Length of Employment: From ____/____/____ to ____/____/____ Position Held: _____________________________
Nature of Work: ____________________________________________________________________________________________
Reason for Leaving: __________________________________________________________________________________________
REFEREES (Please list 3 work related referees whom we may contact for a reference)
Referee Name:________________________________________________Referee’s Position: _________________________
Company Name:________________________________________________________________________________________
Telephone: (0 ) ______________________ Fax (0 )____________________
Referee Name:________________________________________________Referee’s Position: _________________________
Company Name:________________________________________________________________________________________
Telephone: (0 ) ______________________ Fax (0 )____________________
Referee Name:________________________________________________Referee’s Position: _________________________
Company Name:________________________________________________________________________________________
Telephone: (0 ) ______________________ Fax (0 )____________________
I hereby authorise the above referees and employers to provide written and verbal information about me in the form of
personal and employment related references.
Applicant Signature: _________________________________Date: ___/___/____
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SECTION 5 – CRIMINAL CONVICTIONS
The Criminal Records (Clean Slate Act 2004) came in to effect on 29 November 2004. This allows people to conceal those
convictions, so long as
•
You have not been sentenced to a custodial sentence this includes corrective training and home detention
•
Has not been committed to a mental hospital in place of a sentence of imprisonment
• Has not been convicted of a specified offence (sexual offences)
•
Has no fines or reparation payments out standing
• Has not been indefinitely suspended from driving
• Has not been convicted in the previous 7 years.
Have you ever been convicted of a criminal offence excluding any conviction concealed under the Criminal Records (Clean
Slate) Act 2004? Please give details
_________________________________________________________________________________________________________
Have you ever been placed on a Police Diversion Programme? If yes please give details
___________________________________________________________________________________________________________
Are you waiting the hearing of any charges in any Civil or Criminal Court of law? If yes please give details
___________________________________________________________________________________________________________
Do you hold a current Drivers licence? if yes what class? ________________________________
Drivers licence Number: __________________________ Special Conditions: _________________________________
Number of Demerit points: _________________________
Do you have any cases pending that may affect your licence? Write answer here _______________________________
All applicants please complete Ministry of Justice’s Priv/F2 Request by 3
rd
party Under the Official
Information Act 1982 for a copy of individuals Criminal Convictions held on the Ministry of Justice’s
Computer Systems.
•
Applicant please complete Section 1 - Tick Pre Employment Vetting
•
Applicant to complete section 3 and section 4
SECTION 6 – IMMIGRATION
New Zealand Immigration Legislation limits employment in New Zealand to New Zealand Citizens, Residents and holders of
Current work permits.
Are you a citizen or resident of New Zealand Yes: No:
If No do you hold a current work permit Yes: No:
Copy of current work permit attached Yes: No:
Evidence of Eligibility for Employment in New Zealand will be required prior to any offer of employment
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SECTION 7 – GENERAL
How did you find out about positions available at Pak’nSave Kilbirnie?
Website In-store Job Board City Life Staff Referral Other _____________________
Do you have a spouse, partner, relative or household member working in this company or elsewhere in the industry?
If yes who?___________________________________________Where?_______________________________________
Do you have secondary employment? If yes please give details ____________________________________________
Do you have any commitments or interests that may interrupt your regular attendance at work?
__________________________________________________________________________________________________
How would you get yourself to and from work? _______________________________________________________
Have you worked shifts before? Yes: No:
Are you prepared to work shifts? Yes: No:
Are you prepared to work extra hours? Yes: No:
Are you available to work school holidays? Yes: No:
Are you a member of a Territorial Force Unit or Volunteer Fire Brigade? Yes: No:
Have you been served with a Trespass Notice from Pak’nSave Kilbirnie in your current name or any other name?
If yes provide details
Yes: No:
Names:__________________________________________ Date Trespass notice Served: _____________________
If you are offered a job, when could you start work? _________________________________
Would you have another job while working at Pak’nSave Kilbirnie Yes: No:
At Pak’nSave Kilbirnie we require employees to perform alternative duties as and when required such changes in duties may
be on either a temporary or permanent basis, would you be agreeable to this?
Yes: No:
SECTION 8 – ADDITIONAL INFORMATION
Do you have any additional information that you consider may assist you in seeking employment here?
For example, Achievements, Interests, Aspirations Goals etc.
If so, please attach to this form (bearing in mind the declaration in Section 10).
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
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SECTION 9 – OCCUPATIONAL HEALTH
All employment positions in this company involve 80% -100% Visual and Hearing and 90%-100% Physical Demands often
and routinely. Your duties may involve any of the following; lifting (medium to heavy weights), standing for long hours/
standing and walking on a concrete floor, turning, twisting, bending, stretching, working on/from ladders, very few job tasks
involve working while seated.
Note: These duties may vary from time to time as needed to operate a successful business:
Do you suffer from any injury, ailment or condition which may effect your performance or regular attendance at work, or
which may adversely affect the health and safety of yourself or others?
If so, please give details:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Are you presently receiving medical treatment, or under medication which may adversely affect your performance or regular
attendance? If yes please give details
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Have you been absent from work (other than for annual holidays) at any time during the past 2 years? If yes please state
reason and duration of absence?
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Have you ever suffered any back injury or back strain? Yes: No:
Have you ever suffered from any overuse injuries e.g. RSI or OOS? Yes: No:
How many days absence due to sickness have you claimed in the last 12 months of employment?
0-2
3-5
6-10
11-15
16-20
over 20 days
Are you allergic to, or have sensitivity to any substances or chemicals? (For example, soap powders, flour dust, cleaning
materials etc.) If so, please give details
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
SECTION 10 – DECLARATION
I, (Job Applicants full name) ____________________________________________________________________ hereby declare
that to the best of my knowledge, the answers I have given to all sections 1-9 of this Application for Employment Form are
true and correct. I understand that if any false information is given, or any material fact suppressed, I may not be accepted
for employment, or if I am employed, the Employer may justifiably dismiss me at any time on these grounds. I also
understand that any false information given in Sections 9 Occupational Health Medical portion of this form, may result in my
loss of entitlement for any form of employer-related compensation for injury or medical condition by gradual process injury,
disease or infection that may be aggravated or contributed to by any tasks that I may be called upon to perform for the
Employer.
Job Applicants Signature ________________________________________Date: ____/____/____
IN-CONFIDENCE WHEN COMPLETED
Privacy Unit
Ministry of Justice
National Office
P O Box 2750
WELLINGTON
REQUEST BY THIRD PARTY UNDER THE OFFICIAL INFORMATION ACT 1982 FOR A COPY OF AN INDIVIDUAL'S
CRIMINAL CONVICTIONS HELD ON THE MINISTRY OF JUSTICE 'S COMPUTER SYSTEMS
I hereby authorise the Privacy Unit, Ministry of Justice, to release a copy of my personal information, to the undersigned
Third Party, for the purpose of:
Full Name of Third Party
Third Party Name Details
Suburb
City
State / Province
Post Code
Country
Page 1 of 3 Form continues overleaf
X
Signature of subject and date
SECTION 1: SUBJECT'S AUTHORITY TO RELEASE INFORMATION TO A THIRD PARTY
Full name and address of the person or agency the third party is acting for
(if applicable)
Third Party Address Details
X
Signature of Third Party
SECTION 2: THIRD PARTY DETAILS
I wish to receive a copy of the
information provided to the Third party.
Yes / No
The Ministry of Justice will process this request as soon as is reasonably practicable, and in any case no later than 20
working days from receipt of this application.
This application and associated letters and reports will be disposed of three months after processing the response.
Pre-employment vetting
Other (specify)
X
The term "subject" refers to the person whose criminal convictions is being requested.
The term "third party" refers to the requestor or ultimate intended recipient, such as an employer, insurance
company, credit agency et cetera.
For Office Use Only
MoJ Request Number
Priv/F2
Third Party Reference Number
(if applicable)
Insurance Claims vetting
All convictions report Traffic Convictions Report
Tick the report required:
Street Address
P.O. Box or
Surname First Name Middle Names (separate by comma)
Date of Birth
(DD/MM/YYYY)
Place of Birth Gender (Male / Female / Indeterminate)
Personal Details
Surname First Name Middle Names (separate by comma)
Suburb
City
State / Province
Post Code
Country
Previous Names - Maiden Name, Aliases
Postal Address
SECTION 3: SUBJECT'S DETAILS (Please print in pen)
Page 2 of 3 Form continues overleaf
Current Residential Address
Street Address
Suburb
City
State / Province
Post Code
Country
Previous Two Residential Addresses
Street Address
Suburb
City
State / Province
Post Code
Country
Street Address
Suburb
City
State / Province
Post Code
Country
Daytime Phone Number
Home Phone Number
Fax Number
Priv/F2
Street Address
P.O. Box or
Please attach a photocopy of the subject's identification. The identification may be a Driver Licence OR if subject does
not hold a driver licence, a Passport. If subject has neither, the subject will need to complete Section 4.
Subject's Identification
Driver Licence
Passport
Page 3 of 3
Street Address
Suburb
City
State / Province
Post Code
Country
SECTION 4: PROOF OF IDENTITY
ONLY TO BE COMPLETED IF SUBJECT DOES NOT HAVE A DRIVER LICENCE OR PASSPORT
Subject to ask someone who can confirm their identity to fill in th is section
The person who identifies sub ject must:
- have known subject for more than 12 months
- be aged 18 years or over
- have a day time phone number
- not be a relative
- not live at the same address
- be contactable during normal business hours
Surname First Name Middle Names (separate by comma)
I declare that I have personally known:
Surname First Name Middle Names (separate by comma)
for
years and vouch for his/her identity
X
Signature of identifier
If subject is unable to get someone to complete Section 4, they must complete a statutory declaration. The relevant
form can be obtained from the local District Court or by contacting the Privacy Unit on 04 918 8800.
SECTION 3: SUBJECT'S DETAILS (continued)
Home Phone Number
Fax Number
Daytime Phone Number
Priv/F2
