Application for Employment As part of the employment process we gather and confirm as much relevant information as possible for the role you have applied for. This is to ensure we select the best person possible for the role and to also ensure we meet various legislative requirements. Applicants must complete this form personally, answer all questions, and agree to the declaration. All applicants have the right to access personal information and to request any correction necessary to ensure its accuracy. The information you provide will assist us with the selection process. If you are the preferred candidate, in addition to reference checking, further background checks may be undertaken if required, for the role you have applied for. These may include pre-employment medical, drug/alcohol testing, qualification verification, criminal history, financial checks, Police vetting, occupational registration verification, licence verification and occupational membership verification. We seek, as part of this employment declaration form, your written consent in advance to undertake such checks if you are the preferred candidate. First Name * Last Name * Email * Phone * Position Applied For * When are you able to commence employment / what notice period do you have to provide your employer? * Do you have any personal, medical or health related issues that may affect your ability to carry out duties? * —Please choose an option—YesNo If yes, please specify Do you hold a current NZ driver licence? * * —Please choose an option—YesNo If yes, what class/es? Have you ever been convicted of a criminal offence (not including any concealed under the Criminal Records (Clean Slate) Act 2004)? * —Please choose an option—YesNo If yes, please specify Are you awaiting the hearing of charges in a civil or criminal court of law? * —Please choose an option—YesNo If yes, please specify In the last 3 - 5 years have you received any compensation or loss of earnings payments from ACC? * —Please choose an option—YesNo If yes, please specify details Candidate Declaration I give my permission for Everest and the prospective employer to access, discuss and/or use the information arising from any medical questionnaire/report that I may be asked to complete or subsequent medical examination completed. I declare that to the best of my knowledge, the answers in this application are correct and I understand that if any false or deliberately misleading information is given, or any material fact suppressed, I will not be accepted, or that if I am employed, my employment will be terminated. I also understand that Everest has the right to withdraw their services at any stage of this process should it be found that any of the above information has been misrepresented or intentionally suppressed. I also understand that in agreeing to this application, I accept that Everest Group Ltd does not accept liability for any missed employment opportunities. I agree to the declaration * I give permission for my referees provided to be contacted by Everest Recruitment * Full Name * Date *