Allied Security Application for Employment

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PLEASE POST OR FAX TO: Allied Secgrity Head Offige 55 London st Hamilton. or fax to HR Manager 03 8343377 Note: The completion of this form
applicant. Please
does not indicate that there is any obligation on the Company to engage the

Print

DATEOFAPPLICATION:

TZ

ITI iZ

YOUR NAME flN BLQCK LETTERS)

Surname 'K,
FirstNames (underline name YOT]R HOME ADDRESS
Address

used)

fli"\^*

& TELEPHONE NUMBER:

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13

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cellphone,

, A*Jd*ni

Home phone No.

fcl)
is/

55

t 15:o
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Height

lSOcvn Weighr 80ir3

(This information is requi

to veriS details on licences etc)

CONTACT PERSON
(In the event of unforeseen circumstances at work we need someone to contact in any emergency necessity of this information)

hence the

tlurn.

f;O..r-,t.rr,r {o\",^,nso

rn

conracrAddress

BA

lt^netl Croru^t
After hours

Phone-naytim6955t 357o
Have you ever worked f6r this Company before?

YES@

If yes, where

and when

ENTITLEMENT TO WORK

AreyouaNewZealandorAustraliancitizen....ffiNo......ifyes,wtrictrz...Nt.C.:L),..eg.n.
Are you legally entitled to work in ]t{ew Zealand (do you hold work applied

for.)

New Zealand Work Permit ggvering the type of

gpNo
YESNO

Do you hold a visitor or student work permit covering the type of work applied

for

2
Do you have a current driver's license?

If yes, what class: I

Drivers License

No D&B

756
4q6

Drivers License Expiry

nateC6flV2ol8

Drivers License Version

Do you have any demerit points or

endorsements?

yES@

If yes, please

aetuit, I
\iseqse.

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lo&'

e"dorserne

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QUALIFICATIONS
the position applied for. (Give details below)

Do you have any other qualification/certificates/licences/or attended any course which you consider relevant to

Do you have a COA (security

license)?

y\11

Number

PREVTOUSEIMPLOYMENT_REFEREES
Give name, address and telephone numbers of at

see c\J.
referees.

Name

Position

Address

Phone No.

I consent to the Company Dvv\rtr6 verbal or written information about me from reggqentatives of my previous !v luw vvruy4rrJ seeking Yslu4l ul wllrr9ll uu(,rruiluull auout Ine Irom rep[lfgntal employers and referees and authorize the information sought to be released.

Cg9No

Signature

Date

rzftfn

ABILITY TO DO JOB APPLIED FOR

lar skill do you bring to

b.

Do you have other employment?

If yes, please detail Gnnvr",,\^r

(Note: -This information is very i

bb,Lr,r.
must be completed accurately)

@inoo

Are you able to work additional hours, shifts or weekends and public holidays? Do you have any personal responsibilities that may prevent you devoting your

/NO

position

applied?

fulltimejlrd attention to the

0^O
nrbl.hro,[ooA r n& ewm*wh

If YES, then

please explain:

-11^is

iot u"*t bo o"f \f,e" T o*r i'.ucl'g ,^ , t

EXISTING AND PREVTqUS CONDITTONS

Do you have, or have you suffered from, any physical, medical, or other condition which may affect how you do the job you have applied for, and in particular any of the following:

Dermatitis

A Publicly Notifiable disease

YES@
YES/ISD

High or Low blood Pressure Hearing Diffrculties

Heart Problems Diabetes

YESA@
YESn(b
YESNgD

Eczema/otherskininfections YESA@ Hemia YESAfb

Back strain/other back Eye problems Occupational Overuse

injury YES/16
YESir@

rYtssnqo YES/EP

Epilepsy
Blackouts/F{eat exhaustion Nervous Disorder/Anxiety

Vs4p
YESNP

YEsng'
YESi@

Allergies

Insect; dust; food; or chemical

If the answer yes, please give details below:

!!at9 any other injury or illness that you have suffered that may affect your ability to perform tasks and discharge the responsibilities ofthe position applied for:

Do you agree to provide a copy of recent medical history from your GP or other medicalprofessional,

requested?

6nro

if

CONVICTIONS

- LEGAL

ACTIONS

Have you ever been convicted ofany criminal offence or serious traffic offence not covered by clean slate legislation, or are yoq cunently awaiting trial on any criminal or civil matter?

YES/@
lfyes, details
please

Please add your signature after this question

if you consent to the Department of Courts or any other organisation releasing such information in support of this employment application

signature

'fiN\y "[qP

,A

OTHERINTERESTS
What are your interests outside work?

GENERAL
Are you a member of any tenitorial force unit? YES/(p If so, have you completed any basic YES/ID Do you consent to the Company retaining any information contained in this applicution fo.F@fNO

training?

Ifyour application is accepted when could you commence employment?

DECLARATION

(full name to be printed by applicant) declare that to the besl in this application are correct and I understand that ifany false or deliberately misleading information is given, or any material fact suppressed, I may not be considered for employment' or if I am employed, my employment may be terminated. I also understand that any relevant false information given may result in my loss of entitlement for any compensation from ACC or any other injury insurer.
of my knowledge the

I further accept that if I am successful in this application and commence with employment with the Company, the information contained herein and any other information gathered in my course of my employment will be available to Management; and in addition, I clearly understand that my employment does not commence until I have signed my employment agreement.
Signature of Applicant: Date:

Applicqnts must ensure they clearly understand and accept the reasons for requesting the information above, AND FURTHER that they clearly understand the implications of their giving authority to provide information or allow information to be gathered.

(Office use only: Confirmation that licences, certificates, permits etc have been viewed and verified as current) Name: Signed: on behalf of Allied Security