Name

Date Of Birth

Phone

Email

Address

Do you have the right to work in New Zealand? Do you have the right to work in New Zealand? Yes No

Visa Type - If not a New Zealand citizen or permanent resident. (Please type NA if not applicable)

What position are you applying for? What position are you applying for? Registered Nurse Healthcare Assistant / Carer

Qualifications related to the role:

Please list any previous jobs you have had that relate to the job being applied for:

Do you have any medical conditions, injuries, allergies, or impairments that could affect your ability to undertake duties that are required by this role? If so, please list:

Phillips Healthcare requires all employees to undergo a Police check. Please confirm that you consent to Phillips Healthcare to perform a police check: Phillips Healthcare requires all employees to undergo a Police check. Please confirm that you consent to Phillips Healthcare to perform a police check: Yes No

If you have not lived at the above address for more than five years, please confirm your address prior to the one you have written above:

Please provide three referees who we may contact in respect of your suitability for this role (Name, Relationship, Contact Information):

I consent to Phillips Healthcare seeking confidential information for the purpose of assessing my suitability to the role being applied for: Y/N I consent to Phillips Healthcare seeking confidential information for the purpose of assessing my suitability to the role being applied for: Y/N Yes No

In your own words please tell us why you have applied for this position:

Do you have any other comments you would like to add to your application: