ࡱ>  ܰbjbjVV 0<<UJ J 8)..`)")")")"#%4-'-------/}2->)#"#>)>)-)")"g. + + +>)R8)")"- +>)- + + ++)"Z)+-}.0.+13f*13+13+'>(, +3($W('''--*'''.>)>)>)>)13'''''''''J S: Methanex New Zealand Limited Telephone: 64 (6) 754.9700 409 Main North Road, SH3 Motunui Facsimile: 64 (6) 754.9701 Private Bag 2011 New Plymouth 4342 New Zealand Application for Employment THE PRIVACY ACT 1993 The information which you supply on this Application Form is solely to assess your suitability for employment with Methanex New Zealand Limited. Failure to complete all sections truthfully will render this application invalid and, should you have been successful in your application, can be grounds for dismissal. Any false information given in the Health section of this form may also result in the loss of entitlement to any compensation from ACC. This information will be held secure in Methanex Personnel files in the Human Resource File Room and under Methanex rules of access. No information will be disclosed to third parties without your authorisation, except as required by law. Information on unsuccessful candidates will be confidentially destroyed after six months. You have the right to view your personal information held by Methanex in the presence of a Human Resources representative, and may request correction if necessary. DECLARATION I hereby declare that I have read the above Privacy Act statement and am aware of my rights under the Privacy Act 1993. (By typing your name here you are electronically signing this form. A copy of your email and form will be kept for our records). Signed:  FORMTEXT       Date:  FORMTEXT       Position Applied For:  FORMTEXT       (See attached position description for duties, responsibilities and competencies) How did you find out about this vacancy?:  FORMTEXT       Applicant Details Full Name:  FORMTEXT       Address:  FORMTEXT        FORMTEXT        FORMTEXT       Postcode FORMTEXT       Email Address:  FORMTEXT       Telephone: Mobile:  FORMTEXT       Home: FORMTEXT       Are you a New Zealand Citizen?  FORMCHECKBOX  FORMCHECKBOX  Yes  FORMCHECKBOX  No If NO, do you have a valid NZ work permit?  FORMCHECKBOX  FORMCHECKBOX  Yes  FORMCHECKBOX  No (Valid to:  FORMTEXT      ) (A copy of this permit will be required if employment is offered to you) Do you hold a full New Zealand driving licence?  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Yes  FORMCHECKBOX  No If duties require, are you prepared to undertake shiftwork?  FORMCHECKBOX  FORMCHECKBOX  Yes  FORMCHECKBOX  No Additional hours may be required from time to time. Are you prepared to work a reasonable number of non-rostered hours?  FORMCHECKBOX  FORMCHECKBOX  Yes  FORMCHECKBOX  No Do you have any criminal convictions or pending criminal charges?  FORMCHECKBOX  Yes  FORMCHECKBOX  FORMCHECKBOX  No (not including any concealed under the Clean Slate Act) Do you have a professional or personal association with any current  FORMCHECKBOX  Yes  FORMCHECKBOX  FORMCHECKBOX  No Methanex employee? If yes please advise  FORMTEXT        FORMTEXT        FORMTEXT        AUTHORITY FOR BACKGROUND CHECKS I hereby authorise Methanex to carry out background checks as is necessary to assess my suitability for employment with Methanex. This may include credit checks, police checks & verifying education and qualifications. (By typing your name here you are  electronically signing this form). Signed:  FORMTEXT       Date:  FORMTEXT      Educational History Education/Qualifications What School/Industry Training Organisation/Polytechnic/University qualifications do you have? 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 FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT      >?   ƻƻ~q~q~~aS~B jhs~hQ>*OJQJUhs~hQ6CJOJQJhs~hQ56CJOJQJhs~h(`CJOJQJhs~hQCJOJQJhs~hQOJQJhs~hQ5CJOJQJhs~hMmH sH hs~hQ5CJaJhs~hQCJaJhs~hQCJOJQJaJhs~hQ5CJOJQJaJ3jhs~hQ5CJOJQJUaJmHnHu?b7$ J $d %d &d 'd -DM N O P Q a$gd>4 J $d %d &d 'd -DM N O P Q gd>gdM$a$gdQ J gdQ J  6$gdQ \ %gdQ   FHt $  %a$gdQ $ J a$gdQ9$  C%$d %d &d 'd -DM N O P Q a$gd>7$ J $d %d &d 'd -DM N O P Q a$gd>   246@BDFHrtvθΪθΪ~scT?(jhs~hQ>*CJOJQJUaJhs~hQCJOJQJaJhs~hQ5CJOJQJaJhs~hQCJaJhs~hQOJQJ&jths~hQ>*OJQJUhs~hQCJOJQJhs~hQ>*CJOJQJ+jhs~hQ>*OJQJUmHnHu jhs~hQ>*OJQJU&jhs~hQ>*OJQJUhs~hQ>*OJQJvDvx¨˜zk[K[?*(jhs~h!>*CJOJQJUaJh!CJOJQJaJhDLh5CJOJQJaJhDLh!5CJOJQJaJhs~hQCJOJQJaJhs~h]^2CJOJQJaJhs~hQCJOJQJaJhQshQ>*CJOJQJaJ3jhs~hQ>*CJOJQJUaJmHnHu(jhs~hQ>*CJOJQJUaJ.jhs~hQ>*CJOJQJUaJhs~hQ>*CJOJQJaJD,.jlyj$  a$gdA $  a$gdQ $  a$gdQ $  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(By typing your name here you are  electronically signing this form). Signed:  FORMTEXT       Date:  FORMTEXT      Name: FORMTEXT      Name: FORMTEXT      Position: FORMTEXT      Position FORMTEXT      Company: FORMTEXT      Company: FORMTEXT      Email :  FORMTEXT      Email: FORMTEXT      Telephone: FORMTEXT      Telephone: FORMTEXT       Medical Details MEDICAL DECLARATION I hereby declare that to the best of my knowledge the medical information provided below is true and correct. I understand that if I progress to interview stage I will be required to undertake a pre-employment medical assessment including a drug screening test. (By typing your name here you are  electronically signing this form). Signed:  FORMTEXT       Date:  FORMTEXT      Do you have (or have you had) any illness, disability, injury or medical condition which might affect your ability to consistently and safely carry out the duties of the position as described in the Position Description?  FORMCHECKBOX  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please give details:  FORMTEXT       Have you had any extended periods off work (more than 5 days) due to illness, accident or a medical condition in the past 2 years?  FORMCHECKBOX  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please give details:  FORMTEXT       Have you ever suffered from any gradual process or other injury (eg OOS/RSI/Back strain) that the tasks of this job may aggravate or contribute to?  FORMCHECKBOX   FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please give details:  FORMTEXT       I certify that all the information given in this application for employment is true and correct and understand that if I have intentionally omitted important information or provided misleading information I may be disqualified from further consideration, or if appointed may be dismissed. (By typing your name here you are  electronically signing this form. A copy of your email and form will be kept for our records). 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