HERITAGE NEW ZEALAND POUHERE TAONGA

APPLICATION FORM
PRIVATE & CONFIDENTIAL

Position Applied for:

Surname/Family Name:
Given Names:
Preferred Name:
Address:
Postcode:
Email Address
Daytime Contact Number:
Alternative Contact Number:

Driver’s Licence No: _____________________________________________

Driver’s Licence Classes: _____________________________________________

Do you have any traffic or criminal convictions or any proceedings pending against
you? YES/NO

If yes, please give dates and types of offence:

Do you have the right of permanent residence in New Zealand? Please note that
you must have residency to be eligible for a permanent role at Heritage New
Zealand. YES/NO

OR

Do you have a work permit to work in New Zealand? If so please provide details
YES/NO

Do you have any health condition that could affect your ability to undertake the
duties required for this position? YES/NO

If yes, please provide brief details and outline what we would need to provide to help
accommodate you in your employment:
Have you had any injury or medical condition caused by gradual process, disease
or infection that may be aggravated or further contributed to by this position? YES/NO

If yes, please provide brief details:

If your application is successful, when could you commence work?

EDUCATION

Please list any school and/or tertiary qualifications plus any relevant courses you have
attended:

EMPLOYMENT HISTORY

Please list the last 3 positions you have held. (Start with the most recent).
Position Held Employer Length of Service Reason for Key Skills Gained/
(Include dates) Leaving Nature of Work

Are there any other personal details you would like to tell us about that you think are
relevant? (non-work activities, interests etc):

Please tell us briefly why you applied for this position:

2
REFEREES:

Please list at least three people you have worked with that you authorise us to contact as
your referees. Ideally referees would include your current Manager, work associates and
a non-work related person.

Name Position/Company Telephone Number

HOW DID YOU FIND OUT ABOUT THIS VACANCY?

Newspaper (which?)________________________________
Website (please specify)_____________________________
Other (please specify)_______________________________
DECLARATION

I, _________________________ (Name), declare that the information in this application

is accurate and complete. I accept that if my application is successful, the falsification or
withholding of information is grounds for dismissal. I understand that false information
given about my medical history may result in my loss of entitlement for any earnings
related compensation from ACC.

I also agree that Heritage New Zealand Pouhere Taonga can contact the above named
referees seeking verbal or written information about me.

I understand that this information is sought for the purpose of being considered for a
position with Heritage New Zealand and will be accessed by the Hiring Manager and
Recruitment Team, but will not be provided to any third party without my prior
agreement.

I understand that under the Privacy Act 1993 I have the right to access personal
information held about me and seek any correction that I think necessary to ensure
accuracy.

Date: _____________________________

PLEASE ATTACH YOUR CV & COVERING LETTER

Any enquiries regarding this application should be directed to:
information@heritage.org.nz