South Pacific Sera Ltd PO Box 2117 Washdyke Timaru 7941 New Zealand Tel: +64 3 687 4050 Fax: +64 3 688 7608 www.southpacificsera.co.nz

The purpose of the information collected in this form is to assist South Pacific Sera Limited (SPS) in the selection of employees. SPS will only hold this information for as long as it is required in the recruitment process (unless authorised in Section 7 of this document). The information will be accessible only to SPS employees involved in the shortlisting and selection of candidates. Please note: SPS may access public information about you through social media sites (including Facebook) to further inform SPS (as the potential employer) in its recruitment processes.

Position applied for:	Click here to enter text.

1. Personal details

Surname:	Click here to enter text.	First name(s):	Click here to enter text.
Current home address:	Click here to enter text.
Postal address if different:	Click here to enter text.	Click here to enter text.
Telephone contact numbers:	Home Click here to enter text.	Mobile Click here to enter text.

Do you hold a current NZ driver’s licence?	Choose an item.	Classes?

Has your Driver Licence been cancelled within the last five years	Choose an item.
Is there any matter pending which could affect the status of your Driver Licence	Choose an item.

Have you ever been convicted of a criminal offence?	Choose an item.
Note: a criminal offence includes, but is not limited to, violence, sexual crimes, drug-related offences, drink driving offences, theft, and dishonesty).

If you answered “yes” please provide details below (description of offence(s) and date(s):

Offence	Date
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Are you awaiting the hearing of charges in any Court?	Choose an item.

If you answered “yes” please provide a description of the charge(s):

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Have you ever been dismissed from a previous position for theft, dishonesty, physical/racial/sexual abuse/harassment or substance abuse?	Choose an item.

If you answered “yes” please provide a description of the charge(s):

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Are you legally entitled to work in New Zealand?	Choose an item.
I attach the following as proof of my status:	Choose an item.

If you are providing a CV as part of your application for employment, then you are not required to complete sections 2 and3 of this form. Proceed to Section 4. Tick the box to confirm CV attached. ☐

2. Education and qualifications (List only relevant education achievements and qualifications. Included short courses and training programme. Use additional pages if required).

Achievement/qualification	Educational institution/school/college	Date achieved or qualification granted
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3. Work experience (List your current/latest employer first. Use additional pages if you require)

Name and location of employer	Job title	Key tasks in job	Dates of employment	Reason(s) for leaving
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4. Referees (Please provide the names and contact details of 3 referees that we may contact in relation to this application. Where possible, one referee should be from your current or most recent employer).

It is SPS policy to conduct reference checks on all prospective staff. By completing this section you are giving your approval for us to contact the individuals listed.

Name of referee	Organisation and position	Contact details (telephone numbers)
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5. Health and Safety (The following information is required to assist SPS meet its obligations under the Health and Safety in Employment Act 1992 and any amendments, and the Accident Compensation Act 2001 and any amendments).

Do you have any known health condition (medical, injury, disability) of any kind, which may affect your ability to effectively carry out the functions and responsibilities of the position applied for?	Choose an item.

If yes, give details:

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If you have a known condition, do you have any particular requirements to ensure your health and safety in the workplace? E.g. provision of specific equipment, access requirements etc.?	Choose an item.

If ‘yes’, please provide some details:

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Have you had an injury, or do you have a medical condition caused by a gradual process, infection or exposure (e.g. back injury, hearing loss, sensitivity to chemicals, occupational overuse syndrome) which the tasks of this job may aggravate or adversely affect?	Choose an item.

If ‘yes’, please provide some details:

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Do you take any medication which may affect your performance in the position that you have applied for?	Choose an item.

If ‘yes’, please provide some details:

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Do you agree to a pre-employment alcohol/drug test?	Choose an item.

6. Availability

If you are successful with this application, how many weeks’ notice are you required to give to your current employer?	Choose an item.

7. Retention of application forms

Once the recruitment process is completed the form will be filed (for successful candidates) in the SPS workforce files.

If you are unsuccessful with this application, do you authorise us to retain your application and details on file for future suitable positions that may become available?	Choose an item.

If you do not wish your details to be retained by SPS, this application and any attached documents will be destroyed.

DECLARATION

I authorise SPS to collect such personal information about me, including from the named referees as is necessary to assess my suitability for employment with SPS and I authorise SPS to disclose such personal information as is necessary for the same purpose.

I understand that I may access personal information about me held by SPS and request correction of that information. This access to information excludes reference checks undertaken by the Organisation and all evaluative or opinion material complied by SPS employees for the purpose of assessing my suitability, eligibility for employment. I consent to SPS verifying my academic qualifications.

Employment with SPS is subject to drug & alcohol testing and any other pre- employment checks relevant to the position applied for. I understand that should I be employed with SPS and fail to meet the required standard on any of these assessments employment will be terminated immediately.

I declare that all information provided by me to SPS is true, accurate and complete and is not designed to mislead in any way. I declare that I have disclosed to SPS all information reasonably having a bearing on whether or not SPS might employ me. I understand that if I am employed and if I have withheld any such information it will render this application invalid and, if appointed, may be grounds for dismissal.

Full Name (print):

Signature:

Send completed application form to:

e. hr@southpacificsera.co.nz

a. 26 Kennels Rd, PO Box 2117, Timaru, 7941