Application Form
(All fields are required)
1. Advertising avenue:
Where did you see this role advertised?
2. Residency status:
Which option best describes your current residency status?
3. Immigration Check:
Part of our employment process is to undertake an immigration check. Do you give consent for this?
4. Conflict of Interest:
If offered this position, will you be voluntarily engaged in any other employment/position that may cause a conflict of interest with CCS Disability Action? If so, please outline below.
5. Police Check:
Part of our employment process is to undertake a full police check, and appointment is subject to a satisfactory outcome. Do you give consent for this?
6. Criminal Convictions:
Do you have any criminal convictions including any concealed under the Criminal Records (Clean slate) Act? If yes, please detail below.
7. Drivers Licence:
Do you have a current NZ photo drivers licence?
8. Demerit Points / Endorsements:
Do you have any demerit points / endorsements?
9. Medical Conditions / Injuries:
Under the Health and Safety in Employment Act 1992 and the Accident Rehabilitation and Compensation Insurance Act 1992, we must ask. Do you suffer from or have you suffered any injury or medical condition, that may impact you doing this job?
10. Medical Conditions / Injuries :
Are there any specific supports, equipment or assistance that CCS Disability Action can provide to allow you to perform this job? If yes, please detail.
11. Information Obtained:
Do you give consent for CCS Disability Action to use your information to assess your suitability for other position vacancies that may arise within the next 6 months?
12. Past Employment:
Have you ever been employed by CCS Disability Action? If yes, please detail when and in what capacity below.
13. Salary:
Please indicate what salary you are looking for
14. Qualification 1:
I have a recognised qualification in Speech Language Therapy
15. Qualification 2:
I have undergaduate paediatric dysphagia training
16. Qualification 3:
I am eligible for NZSTA membership
17. Experience:
How many years post qualification experience do you have?
18. Knowledge:
I have knowledge of the following guiding documents
19. Availability:
If offered the role, when will you be able to commence employment?
20. Declaration:
Do you consent to CCS Disability Action seeking verbal or written information from the referees? I hereby certify that all the information given for my application is complete, true and correct.
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