Application For Employment

Collecting and Holding Personal Information
The information you provide on this application for employment form will be collected and held by
Talley's Group Limited.

Purpose
This information is collected for the purpose of assessing your suitability for employment at Talley's Group Limited, which may include subsequent changes in employment within the Company.

Your Access To This Information
You have a right of access to personal information to seek any correction you think necessary to
ensure accuracy. Note: You should provide complete information in answer to each question unless otherwise advised, regardless of whether you consider it relevant to the position applied for.

 

Position applied for:      

Personal Details
 

First names:   Last name:
   
If you are known by any other names please record them here:
   
Home address:   Postal address:
(if different)
Phone (Home):   Age:
Phone (Mobile):   Date of Birth:
Email:      
Person to contact in an emergency:   Phone:
Address:   Relationship:
Doctors Name:   Phone:
Address:      

 

Education (including University, Polytech or any further training)

Indicate your Qualifications by selecting the Type in the left box and moving your Qualification to the right box using the > buttons

 
Qualifications:



 
 


 

Secondary Education:

Name of School
Years attended


Qualifications
School 1:


School 2:


School 3:


 

Medical History - please answer all questions

  Yes No If yes, please give details

Have you ever suffered any injury which has resulted in you taking time off work in the last 5 years?
 
Are you allergic to, or have sensitivity to any substance or chemicals?
 
Have you ever suffered any back injury or back strain?
 
Have you ever suffered any wrist/shoulder injury or strain?
 
Have you ever suffered from any overuse injuries e.g. RSI?
 
Have you ever suffered from mental illness?
 
Have you had any ACC claim in the last 5 years?
 
Are you taking any drugs or medicine?
 

 

Have you suffered any:

 Yes No If yes, please give details
Migraines
High blood pressure
Hearing loss
Diabetes
Heart complaint
Blackouts or fits/seizures
Asthma
Hernia
Colour blindness
Dermatitis or eczema
Do you have any other condition which may affect your ability to effectively carry out the functions and responsibilities of the position applied for?


 


Employment History

Present or Most Recent Employer:
 

Company:   Position held:
Address:   Nature of Work:
Date Started:   Date Left:
Reason for leaving:      


Next Most Recent Employer:
 

Company:   Position held:
Address:   Nature of work:
Date started:   Date left:
Reason for leaving:      


Next Most Recent Employer:
 

Company:   Position held:
Address:   Nature of work:
Date started:   Date left:
Reason for leaving:      


Do you agree to inquiries being made as to the accuracy of information contained in this application form, or about any other matter relating to your suitability for employment?
 

Please select:      


Have you previously been employed by this Company?
 

Please select:   If yes, when:


Referees - (Please give details of referees that you authorise us to contact, two work-related referees and one personal referee)

Referee 1 details
 

Name:   Position:
Address:   Phone:


Referee 2 details
 

Name:   Position:
Address:   Phone:


Personal Referee details
 

Name:   Position:
Address:   Phone:

 

General - please answer all questions
  Yes No If yes, please give details
Do you intend to engage in other paid work whilst employed with us?
 
Do you know any person currently employed by this Company?
 
Are you awaiting the hearing of charges in a Civilian Court?
 
Have you ever been charged or convicted of a criminal offence in the last 5 years?
 
Do you smoke at work?
Are you prepared to sign an employment agreement, having read all of its terms and conditions? If no, please explain.
 
Have you worked shifts before?
Are you prepared to work as and where directed on the vessel? If no, please explain.
 
Do you have the right to work in New Zealand? If yes, indicate your status:
 
Have you ever applied for work with Talley's before?
 


If your application is accepted when could you commence employment?
 
 

Date:      

 

Search Consent

I understand that if I am employed by Talley's, I may be subject to a search of my bag, vehicle, clothing or any other property of mine that enters the factory site, in accordance with Company rules; in order to detect the possession of unauthorised company property, unauthorised alcohol or drugs.
 


Declaration

I declare that to the best of my knowledge the answers to the questions in this application are correct. I understand that if any false information is given, or any material fact suppressed, I may not be accepted, or if I am employed, I may be dismissed. I also understand that any false information given in Section 3 (the medical portion of this form) may result in my loss of entitlement for any compensation from ACC, and the Company declining to accept any claim.