Application Form

Personal Information

First Name(s):

Last Name:

Preferred Name:

Date of Birth:

Place of Birth:

Nationality:

Street Address:

Suburb:

City:

Post Code:

Phone Number:

Email Address:

Legal entitlement to work in New Zealand:

NZ Citizen/Permanent ResidentCurrent NZ Work Visa

If you have a work visa, what is the expiry date?

Do you have a full New Zealand driver's licence?

YesNo

New Zealand driver's licence number:

What classes are endorsed on your licence?

Do you have access to a registered and warranted vehicle to use in your day to day work?

YesNo

Do you have a current First Aid Certificate?

YesNo

If yes, please provide:

Expiry Date:

Training Provider:

Do you have Careerforce Qualifications?

YesNo

If yes, please state details:

Do you have a relevant higher tertiary qualification?

YesNo

If yes, please state details:

List any additional competencies, skills or attributes you have that you think are relevant to this position:

Employment History

Please list your 2 most recent employers below:

Current (or most recent) Employer:

Position Held:

Start Date:

Finish Date:

Describe the main duties and responsibilities of the position:

Reason for leaving:

Previous Employer:

Position Held:

Start Date:

Finish Date:

Reason for leaving:

Have you previously worked for CBCT?

YesNo

If yes, please provide details of the dates and position:

Do you have any secondary employment?

YesNo

If yes, please provide details including employer, number of hours and type of work:

Referees

Please provide a minimum of two people who you have reported to as your supervisor/manager, who can be contacted by us to provide a reference. If you are currently employed, one referee MUST be your current employer. Please note: Referees may be contacted prior to your interview.

If you have not been employed before or are returning to work after several years please provide contact details of people from whom a confidential (personal) reference can be obtained (this person is to be a non-family member whom you have known for a minimum of two years).

First referee:

Company/Organisation:

Position:

Phone Number:

Email Address:

Second referee:

Company/Organisation:

Position:

Phone Number:

Email Address:

Health

Are you suffering from, or have you ever suffered from, any injuries or medical conditions caused by gradual process, disease or infection (e.g. hearing loss, occupational overuse syndrome, back injury) which may be aggravated by the duties required for this position?

YesNo

If yes, please give details:

Do you have other physical or mental challenges/concerns not stated above that may affect your ability to work?

YesNo

If yes, please give details:

Are you on any medication(s) that may affect your ability to perform the duties required of this position?

YesNo

Note: Any false or misleading information given in relation to your medical history regarding gradual process, disease or infection may result in the loss of entitlement for any compensation from ACC and may lead to the termination of your employment.

Availability to Work

If you are successful, when are you able to commence work?

What type of work are you looking for?

Full TimePart TimeCasual

What days/hours are you available to work?

Do you have a preference for working in either the Child & Youth or Adult Service? (If yes, please specify.)

In some residential services, CBCT provides 24 hours rostered support.

Are you prepared to work a variety of shifts?

YesNo

Have you worked shifts before?

YesNo

What is your Covid-19 vaccination status?

UnvaccinatedOne doseFully vaccinated

Criminal & Traffic Offences

Have you ever been convicted of any offences against the law in New Zealand or in any other country (other than minor traffic offences)?

YesNo

If yes, please provide specific details of all these offences:

Are you awaiting the hearing of a charge in a Civil or Criminal Court of Law?

YesNo

If yes, please provide specific details:

It is a requirement of CBCT that all applicants undergo a Police Vetting Check. For those applying to work in a Child and Youth Service a CYRAS Check through Oranga Tamariki will also be required.

I declare that to the best of my knowledge the answers given in this application are complete and correct. I have read, understood and agree to the provisions of this Application Form. If I am employed before the results of my Police Vetting Check are supplied to CBCT, I understand that my employment may be terminated if the Police Vetting Check reveals information that CBCT considers makes me unsuitable for the job or which contradicts statements I have made in my application. I understand that if I have supplied any incorrect, false or misleading information, or if I have suppressed any material information, I may not be offered the position applied for or, if employed, my employment may be terminated.

Full Name:

Date:

Corstorphine Baptist Community Trust