Family Planning Application Form August 2017

Family Planning
Employment Application Form
Confidential
This information is collected for the purpose of assessing your suitability for employment with Family Planning. It will
remain confidential to the Human Resources Manager and those staff directly involved in the selection process. The
treatment of any information provided will comply with the Privacy Act 1993. You have a right of access to personal
information about you held by Family Planning and you are also entitled to request information about you to be
corrected. This information will be securely held until an appointment is made, after which it will be destroyed, unless
you are appointed to a role and the information will be placed on your personal file.
Please complete this form personally, answering all questions, and sign it. You should attach the form to your
covering letter and resume and send your application to the address listed in the advertisement before the closing
date.
APPLICANT INFORMATION
First name(s): Last name:
Current address:
E-mail address: Would you like to receive our free monthly

Preferred contact method: select e-newsletter? YES NO
Home phone: Cell phone:
Position Applied for: Date available:
Have you been previously employed by Family Planning YES NO
If yes, where, when and in what position?
Have you ever been dismissed or asked to resign from a job? YES NO
If yes, please give details?
Do you have a current full NZ driving licence? YES NO
Do you have any endorsements on your driving licence? YES NO
Do you have access to a vehicle for work purposes if required? YES NO
Are you legally entitled to work and live in New Zealand? YES NO
If you are legally entitled to work because you have a work permit, when will this expire?
AUTHORITY TO PRACTICE (select box if N/A)

Do you have a current New Zealand Annual Practising Certificate/Registration? YES NO
Please attach a copy. If appointed please produce the originals of documentation for sighting.
PROFESSIONAL DISCIPLINE (select box if N/A)

Have you been subject to a professional disciplinary inquiry in NZ or any other country, or have YES NO
knowledge of an event that might give rise to a disciplinary inquiry?
CONVICTIONS AND PROCEEDINGS
Have you ever been convicted of a criminal offence or are you presently awaiting court proceedings
YES NO
for any criminal offence outside of the criteria in Section 7of the Criminals Records (Clean Slate) Act
2004?
Would you be willing to sign Family Planning’s Consent to Disclosure of Information form YES NO
which provides Family Planning with permission to undertake Police vetting?
HEALTH
Do you have any injuries, medical conditions, or other personal circumstances that may be aggravated by or affect
your ability to effectively carry out the tasks and responsibilities described in the position description?
YES NO If yes, please provide details:
Do you suffer from anything that may affect your ability to perform the role for which you have applied (for example
OOS, back injury, stress related illness)?
YES NO If yes, please provide details:
Please note: The Human Rights Act 1993 defines disability as: physical disability or impairment; physical illness;
psychiatric illness; intellectual or psychological disability or impairment; the presence in the body of organisms
capable of causing illness; any other loss or abnormality of a body or mind function; and reliance on a guide dog.
REFEREES
Please provide names of two referees whose consent has been obtained and who may be contacted for a confidential
reference if you are short listed. (It is preferred, at least one should be able to give work-related information and
should have supervised or been senior to you in your current or most recent employment.)
Name Position Phone
Company Email Cell
Referees relationship to applicant:
Name Position Phone
Company Email Cell
Referees relationship to applicant:
Declaration
 I declare that to the best of my knowledge the answers in this application are correct and I understand that if any
false or misleading information is given, or any material fact suppressed, I will not be accepted, or if I am employed,
my employment may be terminated summarily for serious misconduct.
 I agree that I will inform Family Planning if there are any changes to the information that I have provided, whether
during the recruitment process or as an employee should my application be successful.
 I give my permission for referees to be contacted if I am short listed for this position.
 I understand that all members of staff are required to comply with Family Planning policies and procedures, in
addition to legislation and regulation governing organisational function and individual practice.
 I understand that ongoing education and quality improvement are integral parts of employment and I will be
expected to contribute to and participate in appropriate programmes.
Signed: ____________________________________ Date:

(If sent by email, and you are interviewed, you will be asked to sign this form at the interview.)
Applicant EEO Statistics Form
Confidential
Family Planning operates an Equal Employment Opportunities policy

where an equal employment opportunity is defined as a situation in which a person’s race, sex, sexual orientation,
general relationship status, physical disability, age or any other personal characteristic irrelevant to the effective
performance of a job, does not enhance or hinder that person’s chance of winning the job.
This information is gathered to assist in monitoring Family Planning’s Equal Employment Opportunities Policy and is
collected for statistical purposes only.
Please forward this form with your application. It will be separated from your application as soon as it arrives and
forwarded to the Human Resources Manager. The information provided will not be considered as part of the selection
process.
POSITION INFORMATION
Position applied for:
Area/location of position:
Application date
Is the position full time (40 hours per week) Is the position part time
How did you find out about this vacancy? select
other, please state
APPLICANT INFORMATION
Gender? e.g. female
Please select your age grouping
Under 20 years 20 – 29 years 30 – 39 years 40 – 49 years
50 – 59 years 60 years and over
To which ethnic group or groups do you belong to? (tick the box or boxes that apply to you):
Māori Please give tribal affiliation:

Niuean Please specify
Tongan Please specify
Cook Island Māori

Samoan
Indian
Chinese
NZ European
Other ethnic group, please state
If not born in New Zealand, state country of origin
Number of years in New Zealand

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Family Planning

Employment Application Form

E-mail address: Would you like to receive our free monthly

Home phone: Cell phone:

Position Applied for: Date available:

Have you been previously employed by Family Planning YES NO

If yes, where, when and in what position?

If yes, please give details?

Do you have a current full NZ driving licence? YES NO

Do you have any endorsements on your driving licence? YES NO

Do you have access to a vehicle for work purposes if required? YES NO

AUTHORITY TO PRACTICE (select box if N/A)

PROFESSIONAL DISCIPLINE (select box if N/A)

If yes, please give details?

YES NO If yes, please provide details:

YES NO If yes, please provide details:

Name Position Phone

Company Email Cell

Referees relationship to applicant:

Name Position Phone

Company Email Cell

Referees relationship to applicant:

Signed: ____________________________________ Date:

Family Planning operates an Equal Employment Opportunities policy

How did you find out about this vacancy? select

other, please state

Māori Please give tribal affiliation:

Tongan Please specify

Cook Island Māori

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