Position applied for :

Phone number (work) :

Declaration of your medical details and criminal convictions will be kept confidential and will not necessarily discount you from consideration for this position.

Health

The purpose of obtaining the following medical information is to ensure that the environment you may be working in does not aggravate any health problems that you may have, and that you are of sufficient fitness to undertake work duties, without detriment to the health and safety of either yourself or others around you.

Do you have any known condition, medical or otherwise, that may affect your ability to effectively carry out the functions and responsibilities of the position applied for or that may be aggravated or added to by carrying out the tasks required.*

NO / YES - If yes, please detail: *

Do you agree to a medical examination?*	YES / NO
General
Are you legally entitled to work in New Zealand?* If yes, you may have to provide evidence if required.	YES / NO
Have you been convicted of a criminal offence in the last two years?*	YES / NO
Are you awaiting trial or a criminal offence?* Please be aware that under the Criminal Records Clean Slate Act 2004, you are not obliged to declare certain offences which occurred more than seven years ago. If you have any doubts, please seek legal advice before completing these questions.	YES / NO
Do you have a current drivers licence?*	YES / NO
If yes, what class(es)?*
If your application is accepted, when could you commence employment?
Education / Training

Year	Name of school/college	Courses, exams, qualifications

Use this field for further entries if necessary:

Present Employment

Year (from/to)	Employer	Position held

Past Employment

Year (from/to)	Employer	Position held

Skills/Attributes

List any specific skills or attributes you have which are relevant to this position.*

Referees

Please detail the name and contact numbers of at least two referees:

Name	Their position	Contact phone number

Declaration

I certify that the information in this application is true and complete. I authorise H G Leach to obtain references to support my application and I release H G Leach and my referees from any liability caused by giving and receiving this information.

Furthermore, I acknowledge that a false statement may be sufficient cause for termination of employment if my application is successful.

I understand that any offer of employment will be subject to a satisfactory medical clearance and drug test assessment.

Type: I AGREE *		Date: