Pre Employment Questionaire

Requirements

Do you currently reside in the Waikato area?

YesNo

Hold a current NZ Driver's license, and have your own vehicle?

YesNo

Experienced in Rest home/hospital work

YesNo

Residency or Valid Working Permit

YesNo

Note: All staff employed by Griffin Healthcare MUST complete the compulsory Manual Handling training session which costs $50.00, before you begin work. This will be payable at your induction. You are able to apply for a reimbursement of this when you have worked for Griffin Healthcare continuously for 12 months.

Position Applying for

Health Care AssistantRegistered Nurse

Personal Details

First Name

Last Name

Address

Town

Post Code

Home Phone

Mobile Phone

Photo

JPEG images only. File size limit is 2MB

Experience In Rest Home / Hospital

Facility

Dates Worked

Facility

Dates Worked

Facility

Dates Worked

Please comment on your level of experience i.e. TASK THAT YOU HAVE PERFORMED

Are you currently studying?

YesNo

If yes, give details about your study:

Are you currently employed?

YesNo

If yes, where?

and how long?

Reference Checks (Please ensure you have obtained permission from your referees prior to GHC administration calling).

Referee 1

Name

Facility

Phone

Referee 2

Name

Facility

Phone

REGISTERED NURSES to complete

APC Number

Are you IV Certified?

YesNo

Expiry Date

What days/shifts are you available to work?

Monday	Morning (7am-3pm)Evening (3pm-11pm)Night (11pm-7am)
Tuesday	Morning (7am-3pm)Evening (3pm-11pm)Night (11pm-7am)
Wednesday	Morning (7am-3pm)Evening (3pm-11pm)Night (11pm-7am)
Thursday	Morning (7am-3pm)Evening (3pm-11pm)Night (11pm-7am)
Friday	Morning (7am-3pm)Evening (3pm-11pm)Night (11pm-7am)
Saturday	Morning (7am-3pm)Evening (3pm-11pm)Night (11pm-7am)
Sunday	Morning (7am-3pm)Evening (3pm-11pm)Night (11pm-7am)

I declare that all the information given is true and correct.

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