Personal Information Full Name Email Address Date of birth Telephone Drivers Licence Do you have a current driver's licence? Yes No What level of Driver's Licence do you hold? Learners Restricted Full Other Work Information Position Applied for Work required Full Time Part Time Number of hours wanted per week Please tick days available Mon Tues Wed Thurs Fri Sat Sun Please tick nights available Mon Tues Wed Thurs Fri Sat Sun Health and Physical Particulars Have you ever suffered any type of personal injury caused by a work-related gradual process, disease, or infection? Yes No Have you ever had any condition, which is likely to contribute to a work_related gradual process injury, disease, or infection? Yes No Have you ever had any serious illness, operation or accident, or condition, which would hamper your work in this position? Yes No If you have answered yes to any of the above questions please give specific details Have you been charged with any offences in the last 5 years?If ‘yes’, please provide details, if 'no', please type no. Do you have any legal proceedings pending? If ‘yes’, please provide details, if 'no' please type no. Sale of Liquor Act, Gambling Act and Private Security Personnel Licensing Authority Requirements Have you been declined ‘key person’ status in terms of the Gambling Act? Yes No Have you been declined a Duty Managers Certificate? Yes No Have you been declined a Crowd Controller Certificate of Approval? Yes No Employment Particulars Are you legally entitled to work in New Zealand? Yes No Do you have a work permit? Yes No If yes, when does this expire? Work permits or evidence of authority to work in New Zealand may be requested. Referees Please supply the names and telephone numbers of two referees with at least one referee being a previous employer Name Contact Number Relationship Name Contact Number Relationship Work History Last or Present Position Employer Position From To Reason for leaving Employer Position From To Reason for leaving Employer Position From To Reason for leaving APPLICANT’S DECLARATION I CERTIFY that the above information is true and correct and authorise investigation of all information contained herein for the purpose of ascertaining my suitability for employment, including conducting credit and criminal record checks through the appropriate authorities and contacting referees and previous employers. I understand that if I have given false or misleading information or if I have left out any important information, I may not be considered for appointment. If I am appointed before any inaccuracies on this form are discovered, my employment may be terminated. I understand that in some situations, providing false information may amount to an offence under the Crimes Act. I understand that if I accept employment I will be required to sign an Employment Agreement. If appointed, I agree to observe all rules, policies and procedures issued by the establishment.