(All fields are required)
1. Advertising Avenue:
Where did you see this role advertised?
2. Ethnicity :
Please indicate the ethnic group you most identify with from the selection below. This information is gathered for statistical purposes only.
All DHB employees are required to be fully vaccinated for Covid-19 due to the Government Mandated Health Order.
Have you been vaccinated for Covid-19 Help Tip
4. Consent :
Do you consent to the Wairarapa DHB accessing your vaccination records? In relation to the Government mandated Covid-19 Vaccination order for all Health Care workers. This will usually be conducted at the preferred candidate stage.
5. Ethnicity - Other:
If you answered "Other" to the above question please write what ethnic group you identify as below. If you have already stated your ethnicity above please write "n/a" to proceed.
6. Education and Qualifications:
Are you a registered Medical Practitioner with the Medical Council of NZ or eligible for registration with the Medical Council to enable practice within NZ?
Do you hold a current Practising Certificate?
8. Skills & Expertise:
Do you meet the essential skills & expertise required for this role as mentioned in the position description?
Do you meet the essential experience mentioned in the position description?
10. New Zealand Residency:
Do you have permanent residency in New Zealand?
11. Working authority in New Zealand:
Are you legally authorised to work in New Zealand?
12. Criminal Offences:
Have you ever been charged with or convicted of a criminal offence or released from prison?
13. Criminal Offences:
If "Yes", give brief details (or if "No" to the above question please enter "n/a" to this question):
14. Disclosure Statement:
Do you consent to the disclosure to the Wairarapa District Health Board of whether you have been subject to a serious misconduct investigation, either concluded and upheld or currently under investigation, from all previous Public Service and statutory Crown entity employers for the last three years? This will usually be conducted at the preferred candidate stage.
15. Subject of a Complaint:
Have you been the subject of a complaint to your professional body or the Health and Disability Commissioner? Please state either "No", or if "Yes", please give brief details:
16. Conditions that may affect personal ability:
Do you have any condition that may affect your ability to effectively carry out the functions and responsibilities of the position you are applying for. Please state either "No", or if "Yes", give brief details:
I declare that all the information given above is correct, and I give permission for my referees to be contacted. I understand that I may be required to supply originals of any relevant documents supporting this application.
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