APPLICATION FOR EMPLOYMENT

SECTION 1: APPLICATION DETAILS

Position applied for: SENIOR SYSTEMS ENGINEER ___________________________________ Location: GISBORNE Closing Date: __________________________________________________________________________

SECTION 2: PERSONAL DETAILS

NAME AND CONTACT DETAILS:

Family name: First name(s): Postal Address 1: Postal Address 2: Suburb: City: Country:

ALAPPATT JOHN DAIJO 1/39 STOUT STREET

__________________________________________________________________________

WHATAUPOKO GISBORNE NEWZEALAND

Day: 0210525831 Night:0210525831 Mobile: 0210525831

Post/Zip Code: _____4010___________

Telephone:
(Tick preferred) Preferred Email:

daijoaj@gmail.com

SECTION 3: CITIZENSHIP AND RIGHT TO WORK

QUESTION 3A: ARE YOU A NEW ZEALAND CITIZEN? Yes - Go to Section 4 No - Go to question 3B

QUESTION 3B: DO YOU HAVE PERMANENT RESIDENT STATUS? Yes - Go to Section 4

No - Go to question 3C

QUESTION 3C: DO YOU HAVE A CURRENT WORK PERMIT? Yes - Go to Section 4 No - You may not be eligible to work at Ernslaw One Ltd*

*Information about immigrating to New Zealand can be obtained by visiting the New Zealand Immigration Service website: http://www.immigration.govt.nz

SECTION 4: CRIMINAL CONVICTIONS

SECTION 4A: INFORMATION FOR DISCLOSURE OF CRIMINAL CONVICTIONS NOTE: Ernslaw One Ltd requires you to disclose all convictions unless they are covered by the Criminal Records (Clean Slate Act) Act 2004. WHAT MUST YOU DISCLOSE? You must declare all of your convictions if you have: been convicted of an offence within the last 7 years; OR been sentenced to a custodial sentence (e.g. imprisonment, corrective training, borstal); OR been ordered by a Court during a criminal case to be detained in a hospital due to your mental condition, instead of being sentenced; OR been convicted of a specified offence (e.g. sexual offending against children and young people or the mentally impaired); OR not paid in full any fine, reparation or costs ordered by the Court in a criminal case; OR been indefinitely disqualified from driving under section 65 Land Transport Act 1998 or earlier equivalent provision.

DO ANY OF THE ABOVE CRITERIA APPLY TO YOU? No, none of the above criteria applies to me or I have no convictions. Yes, at least one of the criteria applies and I have disclosed my criminal convictions in the table below.

If yes please provide details:

Offence Year Committed Details of sentence

NOTE: The declaration of a minor offence does not mean that you will not be employed. However, the non-declaration of an offence that you are required to disclose will be seen as a misrepresentation of a criminal record and treated accordingly.

SECTION 4B: CRIMINAL CHARGES PENDING DO YOU CURRENTLY HAVE ANY CRIMINAL CHARGES PENDING? No, Yes, at least one pending criminal charge and I have disclosed details in the table below.

SECTION 5: HEALTH AND SAFETY

Ernslaw One Ltd is committed to ensuring a safe and healthy environment. The successful applicant will require a pre-employment medical, drug and alcohol assessment. Ernslaw One Ltd is responsible, as a good employer, for taking all reasonable steps to ensure the health and safety of everyone in the workplace. We must ensure that all our employees can perform the job and related tasks to an acceptable standard, and that we are in a position to provide any support or reasonable accommodation to enable people to perform their work. To enable us to do this, please answer the following question. Do you have any injuries or medical conditions that could affect your ability to do this job? If Yes, please provide details: No Yes

___________________________________________________________________________ ___________________________________________________________________________ SECTION 6: OTHER INFORMATION

HOW DID YOU FIND OUT ABOUT THIS VACANCY? Personal Contact - Please specify: Newspaper - Please specify: Website - Please specify: Other - Please specify: _______________________________________________________________________ _______________________________________________________________________ www.seek.co.nz _______________________________________________ _______________________________________________________________________

SECTION 7: DECLARATION
I understand that if I have given incorrect or misleading information, or have omitted or suppressed any pertinent information in my Application for Employment form, Curriculum Vitae or supporting papers, I may be disqualified from appointment or, if appointed, that my employment will be terminated. I understand that Ernslaw One Ltd may request official confirmation regarding my declaration in section 4A of this Application For Employment form, and in doing so, I will be requested to complete a Ministry of Justice Form Priv/F2 Request by Third Party under the Official Information Act 1982 for a copy of an individuals criminal convictions held on the Ministry of Justices Computer Systems. I understand that completing form Priv/F2 will be voluntary and that I have the right to refuse. I give permission for the referees required by Ernslaw One Ltd to be contacted on a confidential basis. I understand that the information obtained through the referee process is deemed to be evaluative material and will not be disclosed to me. I declare that the information provided in this application is correct and no relevant material/information has been omitted.

___________________________________ Your Signature

____11/07/2013
Date