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Application Form

If you are not a New Zealand citizen or not already living or working in NZ please make sure you read about Immigration and Registration in the Working in NZ section of this website. These contain important information on the criteria and processes that may apply to you. Please also read section for information on how to apply.

Print form

We prefer online applications but if you do not wish to apply on-line please print a copy of the application form and return it to the relevant District Health Board Recruitment Department. You will find their contact details at Contact Us. Please make sure your completed application form has the vacancy reference number for the position you wish to apply for and remember to attach your CV.

Print Form

Please Note - Fields or Sections marked with an * must be completed.

Immigration / citizenship

*Choose one below.



Visa/Permit expiry date.




Note: There is useful information on the Working in NZ section, under the heading Immigration.Please read this information.

 

Position details

Position : 

District Health Board :  

Vacancy Reference Number : 

 

Personal information

* Title : 

* First Name/s :
Middle Name/s :
* Last Name/s :
Preferred Name :

Contact Information

* Contact Phone :
* Mobile/other Phone :
Business Telephone :
Fax Number :
* Email address :

* Address Information (mandatory)
Street Number and Name :
Suburb :
Town / City :
Postal Code :
Country:

 

Attachments

The following file formats are supported: .doc, .pdf

You are required to attach a CV Applying for a Job/Writing a CV.. Please ensure that all details in your CV are up-to-date.

* Attach your CV (select file to upload)

Covering Letter(optional)

Or add any comments in support of your application

 

Authority to practice - Health Professionals

Do you have New Zealand Registration? 

If YES, what is your registration number? : 

If NO, have you applied?  

Do you have a current New Zealand Practicing Certificate?

If YES, what is the expiry date?

Day :  Month :  Year : 

Do you meet the Scope of Practice defined in the Position Description for this position?

Note: For an explanation on Scope of Practice please refer to the section Working in NZ.

You are required to provide evidence of the Scope of Practice issued to you by the Registration Body and will need to present this at interview and have the original document sighted if appointed.

Are there any restrictions or conditions on your Scope of Practice?

If YES, please provide details : 

Are you currently working under suspension or constraints?  

If YES, please provide details : 

Have you worked in the past under suspension or constraints?  

If YES, please provide details : 

 

Drivers Licence

Some positions require you to drive a vehicle.

Do you have a current driver's licence?  

If YES, What is the country of issue  

Expiry Date :

Day :  Month :  Year : 

 

Convictions

* Have you ever been convicted of a criminal offence or do you have criminal charges pending?

If YES, provide details : 

Note: The District Health Boards have a process of verifying this information through the NZ Police or other appropriate authorities for overseas candidates. If offered employment you will be requested to give consent to verify this information prior to commencement of employment.

 

Professional / Other discipline

* Have you been subject to professional/other disciplinary inquiry or have knowledge of an event that might give rise to disciplinary inquiry?

If YES please provide details : 

 

Referees

Please provide names and accurate contact details of three people who have agreed to act as your referee and from whom we may request the referee report.

Referees need to be in a position to comment on your employment history / education / clinical abilities.

At least one referee must be your current or last employer.

Referee 1(mandatory)

* Name :
* Position :
* Organisation :

Contact Address :
*Address 1 :
*Address 2 :
  Address 3 :
* Contact Phone :
Fax :
Email :

 

Referee 2(mandatory)

* Name :
* Position :
* Organisation :

Contact Address :
*Address 1 :
*Address 2 :
  Address 3 :
* Contact Phone :
Fax :
Email :

 

Referee 3

Name :
Position :
Organisation :

Contact Address :
Address 1 :
Address 2 :
  Address 3 :
Contact Phone :
Fax :
Email :

 

Health Status

This question is to ensure that the environment you may be working in does not aggravate any health problems you may have.

* Have you ever had any injury or medical condition caused by gradual process, disease or infection or other means - for example hearing loss, sensitivity to chemicals, repetitive strain injury, manual handling strain - which may be aggravated or further contributed to by the tasks of this position?

If YES, please provide details : 

 

Employment with this District Health Board

* Choose one below.

 

Application information
(for statistical purposes)

How did you first learn of this vacancy? (Select one only)


      please specify:


      please specify:


      please specify:


      please specify:


      please specify:


      please specify:

 

Authorisation and declaration

I declare the information I have given in this application, and in any supporting documentation, is true and complete. I understand that any incorrect or misleading information may lead to disqualification or if appointed, to termination of employment.

I consent to the District Health Board seeking verbal or written information from the referees listed by me. I understand that the District Health Board will seek information from these referees on the basis that the referees will supply the information in confidence as evaluative material for the purposes of the Privacy Act 1993 and that any information supplied by the referee will not be disclosed to me.

*

If you have completed this application form on-line you may be asked to sign this declaration at a later date.