Form

PBI SAFETY GROUP POSITION APPLICATION FORM

Please provide your contact details and application documents in the form below.

PERSONAL INFROMATION

First Name*

Last Name*

Where Are You Located? *

What Position Are You Applying For? *

Mobile Phone Number*

Email*

LEGAL WORK STATUS

Are you legally entitled to work in New Zealand*

Yes

As a New Zealand citizen

Yes

As a permanent resident

Yes

Work Visa

Yes

EMPLOYMENT HISTORY

Company

Job held

Hours worked per week

Length of service

Reason for leaving

Do you consent to PBI Safety Group contacting your presenting employer for the purpose of reference checking?

Yes

REFEREES

Name (Referee One):

Position and Company (Referee One):

Phone No (Referee One):

Email (Referee One):

Name (Referee Two):

Position and Company (Referee Two):

Phone No (Referee Two):

Email (Referee Two):

GENERAL

If your application is successful, when could you commence employment?

What pay/commission rate are you seeking?

Restrictions to hours of work?

Are you prepared to work overtime if required?

Yes

Do you have any legal proceedings against you pending?

Yes

Do you have any past or present medical conditions eg asthma, heart condition, blood pressure, stress?

Yes

If yes, please specify any medical conditions?

Do you have a work and/or non-work related accident/injury history?

Yes

If yes, please specify any injuries

Could a previous or pre-existing injury or illness by aggravated by the requirements of a job or prevent you carrying out its responsibilities?

Yes

Do you smoke?

Yes

Do you have a current driver's license?

Yes

If yes, what class?

Full

Restricted

Learners

Drivers Licence No and expiry:

Do you have any demerit points?

Yes

Computer Packages - Please list an specialised computer packages here:

Do you have a spouse, partner, or relative working elsewhere in the same industry?

Yes

If yes, who and where?

What are your strengths and weaknesses?

What are your long-term goals?

How long have you been looking?

Reason for delay?

Are you interviewing anywhere else?

Yes

If so, where?

Any leave planned for personal/medical/trips in next 6 months?

Is there anything else we should know that may assist us in considering you for employment?

APPLICATION DOCUMENTS

Application Documents*

Please attach your cover letter & CV here (multiple documents can be uploaded).

PRIVACY ACT CONSENT

Do you consent to PBI Safety Group retaining the information contained in this application form for the purposes of considering your suitability for any other position which may arise in the future?

Yes

DECLARATION & CONSENT

I declare that to the best of my knowledge the information provided in this application and in any resume provided is accurate. I understand that if any false or misleading information is given, or any material fact suppressed, I will not be employed, or if I am employed, my employment terminated.

Full Name (Declaration above):

I consent to the Company seeking written and verbal information on a confidential basis about me from stated employers and/or referees and authorise the information sought to be released by them to the Company for the purposes of ascertaining my suitability for the position for which I am applying. I understand that the information received by the Company is supplied in confidence as evaluative material and will not be disclosed to me.

Signature:

Date of signature:

Month/Day/Year

Do you have any questions you would like to ask us?