Position Application Form

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	Thank you for taking the time to complete this form. We need to know as much about you as possible to ensure a good match between the successful applicant and the vacancy. If you are invited for an interview you will be required to complete a medical questionnaire which is related to the position you are applying for.
	Date:
	Vacancy Reference: (E.G. AH09004)
	Position Applied For:
	With: (service)
	Title: Dr/Mr/Mrs/Miss/Ms
	First Name:
	Middle Name(s):
	Family Name:
	Street Address
	Suburb:
	City/Town
	Phone: (Private)
	Phone: (Business)
	Phone: (Mobile)
	Email address: An acknowledgement letter will be sent to you at this address
	Do you have permanent residency in New Zealand?
	Yes
	No
	If no answered to the question immediately above, are you legally authorised to work in New Zealand?
	Yes
	No
HEALTH STATUS
	Have you ever had an injury or medical condition, including those caused by a gradual process, disease or infection which may be aggravated or further contributed to by the tasks of the position applied for?
	Yes
	No
	If yes answered to the question immediately above, please provide details and describe any technical aids, equipment or adaptations to the workplace which you need to make your work easier and/or increase your performance.
	Does the position you are applying for require that you drive a vehicle?
	Yes
	No
	If yes answered to the question immediately above, do you have a current full drivers licence?
	Yes
	No
EDUCATION AND TRAINING:
	Name of Secondary School:
	Number of years attended:
	Country of schooling:
	University / Polytechnic attended:
	Professional / trade qualifications or other specialised training (nursing applicants give date and name of training school):
	Number on practising certificate (if applicable):
	State any restrictions, limitations, conditions on practising certificate:
	Is your scope of practice/registration consistent with the position you have applied for?
	Yes
	No
	Have you worked in the past under suspension?
	Yes
	No
	If yes answered to the question immediately above, please provide details.
	Has an employer/professional body taken any disciplinary action or any legal proceedings (both past and pending) that may affect your ability to carry out the duties of the position or impact upon your practising certificate or registration?
	Yes
	No
	If yes answered to the question immediately above, please provide details
	Have you been charged or convicted of a criminal offence, or are awaiting a hearing of charges in court (refer to Criminal Records (Clean Slate) Act 2004 in position profile)?
	Yes
	No
	If yes answered to the question immediately above, please provide brief details
REFEREES:
	Please enter the details of two referees other than relatives to whom we may refer. If you have been employed before, one of these should be a recent employer and ideally would be your current employer.
	REFEREE ONE:	Name, position, company, address, phone number. How long have they known you?
	REFEREE TWO:	Name, position, company, address, phone number. How long have they known you?
EMPLOYMENT RECORD: Please indicate present state of employment first.
	Please explain any gaps in your employment record. Nursing applicants should complete details of hospital, public/private, country or state.
	Name of Employer:
	Position Held:
	From (month /year):
	To (month /year):
	Reason for leaving:
	Name of Employer:
	Position Held:
	From (month /year):
	To (month /year):
	Reason for leaving:
	Name of Employer:
	Position Held:
	From (month /year):
	To (month /year):
	Reason for leaving:
	Name of Employer:
	Position Held:
	From (month /year):
	To (month /year):
	Reason for leaving:
	Name of Employer:
	Position Held:
	From (month /year):
	To (month /year):
	Reason for leaving:
	Was any of your previous employment under another name?
	Yes
	No
	If Yes, please state your other name:
	Have you been employed by HBDHB previously?
	Yes
	No
If you wish to supply further information, please provide this separately.
	Where did you see this position advertised?
	Newspaper
	Name of newspaper
	Internet
	Name of Site
	Journal
	Name of Journal
	Internal Circular
	Other:
	If appointed, when can you commence duties?
	By submitting this application you have consented to Hawke’s Bay District Health Board seeking verbal or written information on a confidential basis from the referees listed above. Furthermore, you authorise information sought by Hawke’s Bay District Health Board to be used for the purposes of ascertaining your suitability for the position you are applying for.
	Note that incorrect or misleading information, or information suppressed on this form, may result in being disqualified from appointment, or if appointed, in subsequent dismissal.
Conditions of Appointment:
	1. All information given on this form, and that gathered on personnel files during employment, may be accessed by Hawke’s Bay District Health Board’s executives and/or those organisations from which they may seek advice relative to any matter contained on the individual’s personnel file.
	2. Salary, Annual Leave, Sick Leave, Allowances etc. are in accordance with the appropriate employment agreements.
	3. Tenure: The appointment shall generally be subject to 28 days notice in writing except under special appointments or agreements when it shall be determined therein. In the event of misconduct or inability to discharge the duties of the post, an appointee may be suspended from duty at any time by the Controlling Officer, and have their employment terminated on the approval of the Chief Executive Officer/Chief Operating Officer.
	4. Acceptance of employment with Hawke’s Bay District Health Board acknowledges that transfer to other hospitals or units within the organisation’s area, not only in times of emergency, is a possibility. Such transfer will be an inherent term of engagement.
	5. All members of the staff are required to conform to any rules and regulations made by the organisation for the management of services.
	6. Ongoing education is an integral part of employment and staff are expected to contribute to, and participate in, appropriate programs.
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