Personal Details

Surname

First Name

Address

Post Code

Phone

Email Address

Preferred Contact Preferred Contact Phone Email

Work Status

Do you have any condition that would prevent you from wearing personal protective equipment e.g. gloves, earmuffs etc? Do you have any condition that would prevent you from wearing personal protective equipment e.g. gloves, earmuffs etc? Yes No

Are you a New Zealand Citizen? Are you a New Zealand Citizen? Yes No

What is your country of Citizenship?

Do you hold a valid New Zealand work visa/permit? Do you hold a valid New Zealand work visa/permit? Yes No

Please provide details

Fitness for work

The purpose of gathering the following information is to enable Tardis to determine whether you have any medical condition, injury or impairment which may affect your ability to perform the required work. Please give details where required.

Have you ever had significant time off work as a result of an illness, injury or infection that may affect your ability to work for Tardis? Have you ever had significant time off work as a result of an illness, injury or infection that may affect your ability to work for Tardis? Yes No

Have you ever consulted a health professional for a gradual process illness, injury or infection? Have you ever consulted a health professional for a gradual process illness, injury or infection? Yes No

Please give details

Would you be willing to undertake a pre-employment drug test if required? Would you be willing to undertake a pre-employment drug test if required? Yes No

Are you able to supply us with a CV? Are you able to supply us with a CV? Yes No

Training and Qualifications

Please provide details of relevant training and qualifications

Other relevant information

As this application is for a position requiring a current driving licence and access to customer premises, Tardis requires answers to the following questions.

Do you hold a full New Zealand drivers’ licence? Do you hold a full New Zealand drivers’ licence? Yes No

Please indicate which of the driver’s licence class’ you hold Please indicate which of the driver’s licence class’ you hold Class 1 Class 2 Class 4

Learners or full licence? Learners or full licence? Learners Full

Please indicate which of the driver’s licence endorsements you have Please indicate which of the driver’s licence endorsements you have Wheels Tracks

Do you have any criminal convictions, or actions pending which could result in criminal conviction or loss of licence? Do you have any criminal convictions, or actions pending which could result in criminal conviction or loss of licence? Yes No

Statement of Agreement

I have no objections to Tardis verifying the statements I have made on this application form and attached documentation. However, I understand that my current employer will not be contacted without my consent. I acknowledge that Tardis may contact the referees listed for further information. I certify that to the best of my knowledge the answers given and any documents in respect to this application are true and correct. I understand that any position I may be offered will be based on the details provided and if any false information be given or material fact suppressed, I may not be accepted, or if I am employed, I may be dismissed. I understand that my completion of this form does not constitute an offer of employment and that if a vacancy does arise I may or may not be contacted by Tardis. I have no objections to Tardis verifying the statements I have made on this application form and attached documentation. However, I understand that my current employer will not be contacted without my consent. I acknowledge that Tardis may contact the referees listed for further information. I certify that to the best of my knowledge the answers given and any documents in respect to this application are true and correct. I understand that any position I may be offered will be based on the details provided and if any false information be given or material fact suppressed, I may not be accepted, or if I am employed, I may be dismissed. I understand that my completion of this form does not constitute an offer of employment and that if a vacancy does arise I may or may not be contacted by Tardis. Yes, I hereby agree with and accept the above statement No, I DO NOT agree with or accept the above statement