APPLICATION for employment
Please read and complete all sections of this form before you sign and date it.

Position Applied for:
Location:

personal details
Last Name:
First Name(s):
Address:
Email Address:
Home Phone:	Work Phone:	Mobile Phone:

ELIGIBILITY TO WORK IN NEW ZEALAND	Note for external applicants: To be legally entitled to work in New Zealand you should be a New Zealand (NZ) citizen, or have Permanent Resident status, or have a current work permit
Are you a NZ Citizen?	Permanent Resident of NZ	Do you hold a Work Visa	Have you started the Immigration process? Yes No

Internal applicants
Are you an internal applicant currently working for Education Payroll Ltd?
Your Current Role:
Your Current Team:

referees	Please provide details of Three referees - two work related and one character - who we can discuss your application with.
Work Referee 1
Name:
Job Title:
Name of Organisation:
Telephone number:
Work Referee 2
Name:
Job Title:
Name of Organisation:
Telephone number:
Character Referee
Name:
Relationship:
Telephone number:

criminal convictions	Note: If you are successful in securing this position, you will be required to complete a Ministry of Justice Criminal Conviction Checks form; this will be given to you at a later stage. For the following sections, answering ‘yes’ will not exclude you from being considered for the position.
Have your ever been convicted of any criminal offences that are not concealed under the Criminal Records (Clean Slate) Act 2004 (including benefit fraud, but not parking offences)?	Yes	No
If yes, please give all relevant details for each conviction not concealed by the Criminal Convictions (Clean Slate) Act
Do you have any criminal charges pending or under investigation (including benefit fraud)?	Yes	No
If yes to either of the above please give brief details

conflicts of interest
Are you aware of any current or potential conflicts of interest that will interfere or impair your ability to perform work with Education Payroll Ltd?	Yes	No
If yes, please give brief details

CREDIT HISTORY	Note: Due to the nature of the organisation, if you are successful in securing this position, you will be required to complete a credit history check report.
Do you have a clear credit history? This includes not having bankruptcy on your credit record.	Yes	No
If no, please give brief details

FOR COMPLETION AT INTERVIEW STAGE ONLY
PRE-EXISTING CONDITIONS
Do you have, or have you ever had, a medical condition caused by an injury, illness, disability or gradual process that the tasks of the job may aggravate or contribute to, or that may affect your ability to carry out the work of the position applied for? Letting us know that you have a medical condition or disability will not exclude you from being considered for the position.	Yes	No
If yes, please give brief details.

Authority & Declaration	We need your authority to process your application.
I have truthfully completed all sections of this application. I understand that providing misleading information or failing to tell the truth may be grounds for dismissal. I authorise Education Payroll Ltd to collect personal information about me from my referees (if I am shortlisted or the preferred applicant) to assess my suitability for employment with Education with pre-employment checks, and I authorise Education Payroll Ltd to disclose the necessary information to my referees for this purpose. I also authorise the referees I have named to disclose all relevant information to Education Payroll Ltd for the same purpose. I acknowledge that information collected from me may be used for the selection process and where any review of appointment is sought. If you are completing this form online we will ask you to sign this form if you are interviewed.
Signature:	Date:

External Applicants	We require your authority (2nd signature) to process these checks.
I also authorise Education Payroll Ltd to perform bankruptcy and Baycorp checks as a pre-employment check, if I am the preferred applicant (to identify any bankruptcy or known aliases that may be material to my prospective employment with Education Payroll Ltd). If you are completing this form online we will ask you to sign this form if you are interviewed.
Signature:	Date: