YMCA of Christchurch
PO Box 2004, Christchurch
Please complete this form and return it to us along with your CV
and letter of application.
Position applied for
Name
Right to Work
Are you:
A New Zealand citizen ❒ or a permanent resident of New Zealand ❒
If not, do you have the legal right to work in this country?
Yes ❒ No ❒
(If you answer yes, you may be asked to produce your work permit).
Drivers Licence
Do you have a current drivers licence?
Yes ❒ No ❒
Class(es) of licence:
Criminal Office(s)
Have you been convicted of a criminal offence?
Yes ❒ No ❒
Do you know of any criminal prosecutions pending against you?
Yes ❒ No ❒
(if you answer yes to either of the above, please state the nature of the offence and
place it in a sealed envelope marked "confidential" to the Executive Director).
Previous Employment with the YMCA
Have you ever been employed by any New Zealand YMCA?
Yes ❒ No ❒
Position held: Employed from: / / to / /
Your name at the time:
Health
Have you made any claim to ACC of any injury, illness or condition that could be relevant to your employment?
Yes ❒ No ❒
(If yes, please specify):
Have you any specific health problem that could effect your work?
Yes ❒ No ❒
(If yes, please specify):
I agree to undergo a medical examination if required at the expense of the YMCA.
References
I authorise you to contact any of my previous employers in respect of this application.
DECLARATION
I agree that all references and reports obtained by the YMCA for the purposes of this application will be confidential to the YMCA.
The YMCA may retain the information for 90 days following the filling of the position to which this application relates.
I agree that, if appointed, my wages will be paid by direct credit to a bank account nominated by me.
If offered a position, I am prepared to produce my IRD number, bank account number, evidence of educational qualifications, current drivers licence, evidence of citizenship/residency status, if required to do so.
I certify that the above particulars are true and correct and that if it is found that the information supplied was either false or misleading, if appointed, my employment may be summarily terminated.
I am aware that under the Privacy Act 1993 I have the right of access to certain information and to request a correction to it and/or to request that there be attached to it a statement that I can supply to the employer relating to the fact that I have requested a correction.
Signature of Applicant:
Date: