APPLICATION

Your Name

First NameLast Name

First Name

Last Name

Middle Name/s

Email

example@example.com

Phone Number

Post Code

City/Town

Street Number

Street

Suburb

What region are you applying to work in

How did you hear of MindFull?

I am applying for the role of:

Drivers Licence

Right to work

If on a work visa, please provide the expiry date

Expiry

Do you have any past convictions (clean slate doesn't apply for youth police checks)

If Yes, Please provide further information

Are you known to Oranga Tamariki (Part of the youth check, requests information from Oranga Tamariki about past concerns you may have been linked to)

If Yes, Please provide further information

Do you have any health conditions or infectious diseases that could put you or others at risk or impact your ability to perform the role?

If Yes, Please provide details

Please list any qualifications you hold

MindFull mostly works 24hour shifts, how many hours per week are you looking for

If other, please provide details

Which of the below qualifications do you hold?

Relevant work/life experience that supports this application

We require 5 years of employment history due to the Childrens Act 2015. Please provide below.

Last employer

Role held there

Employment start date

Employment finish date

Reason for leaving

Next previous employer

Role held there

Employment start date

Employment finish date

Reason for leaving

Next previous employer

Role held there

Employment start date

Employment finish date

Reason for leaving

Sometimes we have some specialised areas of support that come up. If you have work experience in any of the below please tick. It will not effect your application if you tick none.

If your application is progressed, you will be asked to provide 2x professional referee's, either current/past Line Managers or Supervisors within the last 5 years. Will you be able to provide these?

Other

Any other information you would like to share relevant to your application.

Please upload a picture of the FRONT of your drivers licence

Please upload a picture of the BACK of your drivers licence

Name of Approved Agency submitting vetting request

Which most accurately describes you?

Gender

Date of birth

Date

Place of birth (Town/City/State)

Country of birth

NZ Driver licence number

Have you ever been known by any other name?

If "Yes" please provide details in the box below:

Previous names: If applicable, please include

Rows	Family name	First name	Middle names
Previous Name 1
Previous Name 2
Previous Name 3

Consent to release information

1.The New Zealand Police may release any information they hold if relevant to the purpose of this vetting request. This includes:

Conviction histories and infringement/demerit reports
Active investigations, charges and warrants to arrest
Charges that did not result in a conviction including those that were acquitted (not guilty), discharged without conviction, withdrawn, or resolved by way of the Police diversion scheme
Any interaction I have had with New Zealand Police considered relevant to the role being vetted, including investigations that did not result in prosecution
Information regarding family violence where I was the victim, offender or witness to an incident or offence, primarily in cases where the role being vetted takes place in a home environment where exposure to physical or verbal violence could place vulnerable persons at emotional or physical risk.
Information subject to name suppression where that information is necessary to the purpose of the vet

2. If I am eligible under the Criminal Records (Clean Slate) Act 2004, my conviction history will not be released unless:

a.Section 19(3) of the Clean Slate Act applies to this request (exceptions to the clean slate regime)

b.Section 31(3) of the Children’s Act 2014 applies to this request (safety checks of core children’s workers

c.The vetting request is made by an individual for the purpose of an overseas Visa/Work Permit as a Privacy Act request authorising the vetting result to be provided directly to the relevant embassy, high commission or consulate.

3. Information provided in this consent form may be used to update New Zealand Police records

4.I am entitled to a copy of the vetting result released to the Approved Agency (to be provided by the agency) and can seek a correction by contacting the Vetting Service.

5.The Approved Agency will securely dispose of this consent form, copies of identification documents and the vetting result within 12 months of receiving the result unless a longer retention period is required by legislation.

6.I may withdraw this consent, prior to Police’s disclosure of the vetting result, by notifying the Approved Agency.

I confirm that the information I have provided in this form relates to me and is correct.

I have read and understood the information above.

I authorise New Zealand Police to disclose any personal information it considers relevant to my application

Full Name

Ethnicity

Date.

Applicant Signature

Your Occupation

Ethnicity

Iwi/Village

Applying to work with

Your Current Address has already been submitted - Please provide the last THREE previous places you lived prior to this (New Zealand addresses)

If you are unable to provide three previous New Zealand addresses, please state why in the box below.

Street Number

Street / Road

Suburb

City/ Town

Country

Street Number

Street / Road

Suburb

City / Town

Country

Street Number

Street / Road

Suburb

City / Town

Country

If you are unable to provide three previous NEW ZEALAND addresses, please state why below. E.g Was living in Australia

This question refers to your OWN children (i.e. biological children/adopted children) Do you have, or have you had any children? If yes please enter their details below

This question refers to OTHER children currently in your care Are you currently providing care for children, other than your own, under 18 years of age? If yes, please enter their details below

Details of Own or Other Children indicated above

Rows	Full Name	Date of Birth	Relationship to you e.g. Son	Are they living with you? Yes/No
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 7
Child 8

Are you, your family or household members (if applicable) known to Oranga Tamariki?

If “YES”, provide details in the box below including date, place and circumstance. Include any investigation or appearance in the Family Court for care and protection/custody/guardianship or disputes either in New Zealand or overseas.

Are you currently or have you ever worked with children and or young people?

If "YES" , provide the name of the Organisation/ Employer, your position and dates you were employed.

Please upload a copy of your CV

Privacy statement
MindFull Support collects personal information as part of our recruitment process to assess your suitability for employment and complete relevant pre-employment checks. This may include collecting information from referees you nominate and, where applicable, other authorised third parties.

Your information will be held securely by MindFull Support and accessed only by people involved in the recruitment and employment process. You have the right to request access to, and correction of, your personal information.

By submitting this application, you acknowledge that you have been informed about how your personal information may be collected and used during the recruitment process.

Signature

Date

Application, Police Vetting and Oranga Tamariki Records Check

Employment History

Police Vetting Consent Form

Vetting Service Request & Consent Form

Oranga Tamariki Authority to release information - Child Safety Check

Previous Address 1

Previous Address 2

Previous Address 3

Section 2: Children and Dependents

I confirm all the above information is true and correct