Become a Carer Full Name Email Phone Number Date of Birth Address Emergency Contact / Next of Kin: have a current full driver’s license. I have a car available for work. My car is fully insured. My car is registered and warranted. I am willing to travel to different areas within Christchurch for work. I am legally entitled to work in New Zealand. I hold a current First Aid Certificate. I will obtain a First Aid Certificate if my application is successful. EMPLOYMENT HISTORY Last Employer from to Position Held Reason for leaving Details of experience relevant to position applied for: Please give details of three referees whose consent has been obtained and who may be contacted for a confidential reference. Where possible, at least two referees should be able to give work-related information and one of those should have supervised or have been senior to you in your current or most current employment. name phone number position name phone number position Interests and Hobbies Why do you want to work for us? Are you restricted to working limited hours? yes no Are you available for a 3 hour shift? yes no If “YES” please elaborate, any other commitments How many hours per week do you want to work? referral code The following information is required to assist HOME CARERS to meet its obligations under the Health and Safety in Employment Act 1992 and the Accident Insurance Act 1998. Do you have any medical, psychiatric or physical condition that could affect your ability to do this type of work. yes no Have you had an injury or medical condition caused by gradual process, disease, or infection – eg hearing loss, sensitivity to chemicals, occupational overuse injuries – which the tasks of this job may aggravate or contribute to? yes no If “yes” please give details and describe any technical aids or equipment or adaptations to the workplace we would need to make to ensure your health and safety. Declaration I declare that all the information I have given is true and that any false or misleading information may result in termination of contract with HOME CARE SERVICES. I understand that all information provided by me will be held on a confidential basis and that my permission will be sought before any identifying personal details are released to a third party. I consent to HOME CARE SERVICES undertaking reference checks pursuant to my application for a specific employment position, and recognise that all conducted on a confidential basis, and that HOME CARE SERVICES has the right to maintain confidentiality of this information. I declare that all information provided by me to HOME CARE SERVICES in this Independent Contractor Application is true, accurate and complete and is not designed to mislead in any way. I confirm that I have read and understood the statements in the declaration above. Send
