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Consent to Access Information on Academic Record

I understand that the Palmerston North City Council may require verification of an applicant's academic record. I consent to the Palmerston North City Council seeking verbal or written verification on a confidential basis of my academic record as described in this application form or in any Curriculum Vitae I have provided. I understand that this information will be used for the purposes of assessing my suitability for the position for which I am applying. I authorise the release of this information to the Palmerston North City Council.

Declaration

I declare that to the best of my knowledge, the information supplied in this application and in any Curriculum Vitae provided is correct and I understand that if any false or deliberately misleading information is given, or any relevant material withheld, I will not be accepted, or if I am employed, my employment will be terminated. I also understand that any false information given in relation to my medical history with regards to gradual process, disease or infection, can result in my loss of entitlement for any compensation from ACC. I further understand that any offer of employment if made is conditional on my obtaining a full medical clearance through the Council's pre-employment medical examination or employment check.  In applicable areas of employment credit checks, Ministry of Justice Criminal Conviction checks, and visa checks may be undertaken to assess candidate suitability for a position.  I understand that I may be required to give my consent for these checks and that any offer of employment if made is conditional on the results of these checks.

Consent to Contact Referees

I consent to the Palmerston North City Council seeking verbal or written information on a confidential basis about me from representatives of my previous employers and/or referees and authorise the information sought to be released by them to the Council for the purposes of ascertaining my suitability for the position for which I am applying.  I understand that the information received by Council is supplied in confidence as evaluative material and will not be disclosed to me.

Drug and Alcohol Testing

As part of the Council's Management Team Drug and Alcohol Policy, to ensure the safety of those who come into contact with Council, applicants for employment in safety sensitive positions must undergo a drug test before being employed. All applicants for employment outside of safety sensitive areas may undergo a pre-employment drug test at the Council's discretion.  If an applicant fails the test, he/she will not be considered for appointment, or if the applicant has already been appointed, the employment may be cancelled or terminated.

I consent to Palmerston North City Council having access to and using the information arising from the pre-employment drug test for the purpose of considering me for appointment or if I have already been appointed, the purpose of cancelling or terminating my conditional offer of employment and authorise the information to be released to the organisation.

1. Yes I agree to the privacy statement*

1. Title* Mr Mrs Ms Miss Dr Other
2. First name*
3. Last name*

1. E-mail*
2. Phone*
3. Mobile*

1. Street*
2. Street Cont.
3. City, Town or Suburb*
4. Postcode or Zipcode*
5. Country* AFGHANISTAN ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BRAZIL BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA COTE D'IVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN, PROVINCE OF CHINA TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES URUGUAY UZBEKISTAN VANUATU VENEZUELA VIET NAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE INTERNATIONAL OTHER Unknown
6. State, Region or Province*Please choose...

1. Gender Male Female Unspecified

1. What is your salary expectation?
2. What is your legal entitlement to work in New Zealand? *

   1. New Zealand citizen
   2. New Zealand resident or permanent resident visa
   3. Visa to work in New Zealand
   4. None of the above
3. If you cannot work in New Zealand indefinitely, please explain your circumstances.
4. Do you have any commitments at this time which may prevent you attending your place of employment now or in the future?*

   1. Yes
   2. No
5. If 'Yes', please explain:
6. Do you have a current driver's licence?*

   1. Yes
   2. No
7. If 'Yes', what class(es) do you hold?

   1. Class 1 -Full Car Licence
   2. Class 2 - Medium Rigid Vehicle
   3. Class 3 - Medium Combination
   4. Class 4 - Heavy Rigid
   5. Class 5 - Heavy Combination
   6. Class 6 - Motorcycle Licence
   7. Class 7 - Learners
   8. Class 8 - Restricted
8. Any licence endorsements? Please specify:
9. Have you been convicted of any offence in the last ten (10) years (not concealed under the Criminal Records (Clean Slate) Act 2004)?*

   1. Yes
   2. No
10. If 'Yes', please explain:
11. Are you awaiting the hearing of charges in a civil or criminal court of law?*

    1. Yes
    2. No
12. If 'Yes', please explain:
13. Have you had an injury or illness that may affect your ability to perform the duties of this job?*

    1. Yes
    2. No
14. If 'Yes', please explain:
15. Are you a current PNCC employee? *

    1. Yes
    2. No
16. Have you previously worked for PNCC? If so, please provide details:
17. Did a PNCC staff member refer you to this position? If so, please name:
18. If you are shortlisted for this position, would you like to have whānau/family support at the interview?*

    1. Yes
    2. No
19. Do you have a relevant tertiary qualification?*

    1. Yes
    2. No
20. If yes, please explain:
21. Please explain your relevant experience:*
22. What motivated you to apply for this position?*