Application for employment

Position applied for*
How did you learn of this position?*
Personal details
Name*

TitleFirst namesLast name
Preferred first name*
Other name(s) by which you have been / are known

First nameLast name
Address*

Street address

Street address line 2

CityState / Province

Post codeCountry
Is your postal address different from your address above?*

YesNo
Postal address

Street address

Street address line 2

CityState / Province

Post codeCountry
Mobile phone number*
Work phone number
Email*
example@example.com
Education/professional/trade qualifications and/or associations

Please list in order of relevance to role. Further information may be supplied in your CV such as academic transcript and official results)

	Qualification / membership	Date obtained / current	Institution / association
1.
2.
3.
4.
5.

Current employment (if applicable)
Employer
Position held
Address

Street address

Street address line 2

CityState / Province

Post codeCountry
Starting date
Main responsibilities
Past employment

Please list your last two roles. Non-paid experience may also be listed. Further information may be supplied in your CV.
Job title
Employer
Type of business
Address

Street address

Street address line 2

CityState / Province

Post codeCountry
Starting date
Leaving date
Reason for leaving
Job title
Employer
Type of business
Address

Street address

Street address line 2

CityState / Province

Post codeCountry
Starting date
Leaving date
Reason for leaving
Have you ever been employed by Kāpiti Coast District Council?*
Do you have or have you had a spouse, partner, relative, or household member currently or previously working for Kāpiti Coast District Council?*
If YES, in which Council team/group? Please provide the name of person(s) and state relationship
Referees

Please name two people, preferably recent employers, from whom the Council may request confidential references. We will only contact the referees once we have your verbal consent, should you become a preferred candidate following an interview.
First referees name*

First nameLast name
Position / title*
Postal address*

Street address

Street address line 2

CityState / Province

Post codeCountry
Email*
example@example.com
Phone number
Relationship to applicant*
Second referees Name*

First nameLast name
Position / title*
Postal address*

Street address

Street address line 2

CityState / Province

Post codeCountry
Email*
example@example.com
Phone number
Relationship to applicant*
Drivers licence

Where your position may require you to drive a motor vehicle, the Council requires the following information.
Current drivers licence?*
Class of licence
Do you have any demerit points or endorsements?*
Licence number
Please provide full details any demerit points or endorsement
Resident status
If applicable, in the supporting documents section please provide evidence of your entitlement to work in New Zealand such as:
- New Zealand passport or
- Australian passport or
- NZ Birth Certificate and photo ID such as a drivers licence or
- NZ Citizenship Certificate and photo ID such as a drivers licence or
- For foreign nationals, a valid work permit and photo ID
Are you legally entitled to work permanently in New Zealand?*
If not permanently entitled, what is the term of your work permit?
Previous convictions
You may not have to reveal certain convictions concealed by the Criminal Records (Clean Slate) Act 2004. If you are unsure, seek independent advice. Please refer to www.justice.govt.nz for further guidance.
Do you have any criminal convictions, and/or are you under investigation for any criminal matter?*
Please provide full details
Criminal history, police vetting and credit checks
Some roles require completion of a Criminal History, Police Vetting and/or a Credit Check due to responsibilities associated with the role. A separate form will need to be completed in such an instance.
If required, do you agree to Criminal History, Police Vetting and/or a Credit Check checks?*
Conflict of interest
Declaration of a conflict of interest does not necessarily exclude employment opportunities within the Council. The following question is to ensure we identify any conflicts whether actual, perceived or potential.
Do you have any private or professional interests or associations that have the potential to impact on your ability to carry out, or be seen to carry out, your duties impartially and in the Councils interest? *
If YES, please specify your private/professional interest and/or associations.
Health & safety requirements
Declaration of a medical condition does not necessarily exclude employment opportunities within the Council. The following questions are to ensure you can safely carry out the position.
Are you aware of any current or former medical or health related conditions that could affect your performance or ability to carry out the duties and responsibilities of the position or that may be aggravated or further contributed to by the tasks of the position for which you are applying?*
If YES, please specify the health problems/disabilities.
Do you currently have or have you ever had (including anything that may have resulted in a claim for compensation for incapacity) any gradual process, disease, infection or symptoms of occupational overuse syndrome ("OOS") such as but not limited to aches, pains, numbness, tingling or burning sensations that may affect your ability to carry out the requirements of your position?*
If YES, please provide details including, if applicable, the nature of the condition(s) for which claims were lodged and date of lodgement.
If you have indicated a medical or health related condition that could affect your ability to carry out your job, please indicate whether you would be prepared to undergo a medical examination by a doctor nominated by the Council (at its expense) to determine your ability to perform your job prior to us making a decision about your application?*
If you are currently suffering, or have suffered in the past from injury or illness, are there any special services or facilities which we could provide to enable you to carry out the work duties safely?
If YES, please specify
Are you earning, or do you anticipate that you will earn income from secondary employment?*
If YES, what is the nature of this employment?
If the role you are applying for has been identified as one which requires a completed and current vaccination for any of the following - Tetanus; Hepatitis A, Hepatitis B, and you cannot provide evidence of your completed vaccination programme, are you willing to undertake the required vaccination programme if you are identified as the preferred candidate for this role?*
Supporting documents
Curriculum vitae *

Cancelof
Covering letter supporting your application*

Cancelof
Copy of proof of identity such as : drivers licence, 18+ card, Passport or birth certificate*

Cancelof
Copy of evidence of your entitlement to work in New Zealand (if applicable)

Cancelof
Declaration
Confirm*

I confirm that the information given on this form and in the process of my application is, to the best of my knowledge, true and complete. Any false or misleading statement or omitted material may be sufficient cause for disqualifying me from appointment, or if employed, summary dismissal.
Acknowledge*

I acknowledge that I may be required (at the Councils expense) to undergo a medical examination prior to commencing employment.
Consent*

I consent to Kāpiti Coast District Council seeking:
- verbal or written information about me from my referees, and authorise the information sought to be released
- verification from the NZTA Driver Check database that the details I have provided under the Drivers Licence section are correct
- security checks (such as police vetting, criminal history, credit, financial, drivers licence status, traffic infringements and dismissal register) and agree to co-operate in providing information to assist that vetting process. I further understand that should any offer of employment be made that this will be subject to satisfactory results being obtained from Kāpiti Coast District Council’s pre-employment screening process. In the event that any results are deemed unsatisfactory to Kāpiti Coast District Council then any employment relationship will be terminated.
Date

DayMonthYear
Confidentiality and privacy
This information is collected for the purpose of assessing your suitability for employment at the Kāpiti Coast District Council (the Council) in accordance with the Privacy Act 2020.

The information will be treated as confidential and will only be shared with staff involved in the recruitment process for the purpose in which it is collected. If you are successful in obtaining employment with the Council, the information will be stored on your personal file.

If you are not employed by the Council, the information will be securely disposed of unless we have your prior consent to keep your personal information on file for another suitable opportunity that may arise. You may access personal information held by the Council and request corrections to this information.

Any requests for access and correction should be made to humanresources@kapiticoast.govt.nz.
Please complete all parts of this form. An incomplete application may affect the Council’s ability to properly assess your application.
Should be Empty:

Personal details

Education/professional/trade qualifications and/or associations

Current employment (if applicable)

Past employment

Referees

Drivers licence

Resident status

Previous convictions

Criminal history, police vetting and credit checks

Conflict of interest

Health & safety requirements

Supporting documents

Declaration

Confidentiality and privacy