Position
Name
Address
Home Phone
Work Phone
Mobile
Fax
Email
Referees Please include the names of two or three referees whose consent has been obtained and who may be contacted for confidential reference. (Where possible at least two of the referees 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
Address
Phone
Mobile
Email
Name
Address
Phone
Mobile
Email
Name
Address
Phone
Mobile
Email
Please give the date you are available to start or the period of notice required in your current employment.
Date Available
Notice Required
Are you a permanent NZ resident?
Permanent NZ resident	Yes No
Are you legally entitled to work in New Zealand?
Legally entitled	Yes No
Do you consent John Austin Ltd retaining the information obtained in relation to this application for the purpose of assessing your suitability for other positions for which you may be considered within the next six months.
Do You Consent	Yes No
As part of our pre-employment process you are required to undertake a full medical assessment which will include testing for banned drugs.
Do You Consent	Yes No
The following information is required to assist John Austin Ltd to meet its obligations under the Health and Safety Act 1992, and to assess you ability to do the job. Do you suffer from or have you suffered any injury or medical condition caused by gradual process, disease or infection (eg. repetitive strain injury, occupational overuse syndrome, back injury or strain, hearing loss, sensitivity to chemicals) which this job may aggravate or contribute to?
Medical Condition	No Yes - Please give details
Please Give Details
Do you live with the effects of injury, long term illness, or disability/disabilities? If yes what do they affect (eg. movement, hearing, speech)
Disabilities	No Yes - Please give details
Please Give Details
Have you been convicted of any offence against the law in the last five years or do you have any criminal charges pending?
Court Convictions	No Yes - Please give details
Please Give Details
Have you ever had your employment terminated as a result serious misconduct or not complying with company policy?
Employment History	No Yes - Please give details
Please Give Details
The following information is voluntary. It is collected for statistical purposes to assist with equal employment objectives
Sex	Male Female
Ethnic Group	New Zealander Maori Pacific Islander Other - Please give details
Please Give Details
Please detail employment history and equipment experience.
Declaration I consent for John Austin Ltd seeking verbal or written information about me on a confidential basis from the referees I have nominated and authorise the information requested to be released. I understand that the information will be supplied in confidence as evaluative material and will not be disclosed to me. I hereby certify that all the information given orally and in writing by me for the application is true and complete to the best of my knowledge and belief. I understand that the provision of false, incomplete or misleading information will be grounds for summary dismissal.