Employment Application

GENERAL INFORMATION This online application form will guide you through the process of registering your details for the position(s) you are applying for. Information collected include your: Personal details, any health issues and/or criminal convictions Tertiary education including degrees and diplomas Secondary education including School Certificate, 6th Form Certificate and Bursary/Scholarships Work experience, referees, and achievements Reasons for applying Required information is marked with an asteriks (*). The information requested is to determine your suitability for the position for which you are applying. The information provided in your application, curriculum vitae, written references and details following from interviews, telephone conversations or other authorised information from you or third parties, will be used for the express purpose of considering you for employment. Under the Privacy Act 1993 you have a right to access and correct your personal information. If your application is unsuccessful, we will keep your personal information up to six months after your last contact with us. This is so that we can continue to consider you for positions as they become available. You may otherwise advise us to remove your personal information from our files. Thank you for taking the time to complete our application form. We appreciate your interest in Staples Rodway.

PERSONAL INFORMATION Position applied for * City (1 or more)* Auckland Christchurch Hamilton Napier Taranaki Tauranga Preferred City junkSelect CityAuckland Christchurch HamiltonTaranakiNapierTauranga Title junkTitleDrMrMrsMsMiss First Name(s) * Preferred First Name Last Name * Address * Telephone Number Alternative Address/Ph. No. Mobile Phone Email address Are there any restrictions on your ability to work in New Zealand? * Yes    No If yes, please give details HEALTH Are you aware of any current or former medical or health related condition that may affect your ability to carry out the requirements of the position or that may be aggravated or further contributed to by the tasks of the job? * Yes    No If yes, please specify: CRIMINAL CONVICTIONS As the position requires a high level of trust and confidence, have you ever been convicted of any criminal offence that involves fraud, dishonesty or acts of assault or violence, or are you awaiting the hearing or charges relating to any such criminal convictions? * Yes    No If yes, please give details:

TERTIARY EDUCATION Name of University Year of commencement Degree(s) sought/attained Diploma/Other Degree papers completed and enrolled Year Paper Grade Have you successfully completed your ICANZ requirements? * Yes    No

SECONDARY EDUCATION Name of school(s) School Certificate Year Attained Subject (Best 6 only) Grade 6th Form Certificate Year Attained Subject (Best 6 only) Grade Bursary/Scholarship Year Attained Subject (Best 6 only) Grade Additional Comment (eg: Equivalent papers attained)

WORK EXPERIENCE RELEVANT WORK EXPERIENCE Full-time, part time, vacation Date Commenced Date Finished Employer Position Held REFERENCES Referees will not be contacted without your prior knowledge Name Position & Organisation Contact Number ACHIEVEMENTS Please list any academic, sporting or community acheivements OTHER EXPERIENCE Please describe any other non-employment experience or skills (eg languages, community involvement) that would qualify you for this position

APPLICATION SUPPORT In support of your application, please write why you are applying for this position and what you can offer the position and the firm.

OTHER DETAILS Availability to Start Salary Expectations Do you currently undertake any secondary employment? * Yes    No Are you a member of any professional institiutions? * Yes    No If yes, please list

DECLARATION & AUTHORISATION If you are selected for an interview, you will be required to submit a copy of your academic transcript. If unsuccessful, I authorise the firm to keep this application for six months from our last contact for consideration for any future vacancies Yes    No I understand that by submitting this form I am declaring that the information provided in the process of my application is true and accurate and provides a balanced and complete view of the details relevant for considering me for employment. I understand that any incorrect, misleading or omitted information may disqualify me from appointment, or if appointed, that my employment may be terminated. I also understand that any false information given in relation to the health question of this form may result in my loss of entitlement for any work-related compensation.