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Position and location
Position Applied For:
Do you have any previous experience for the role you have applied for? If yes, please detail:
i Had 3 mos of experience in Life Recruitment Agency (BEUREU) and 8 mos. of experience in Ocenia Group Ltd. ( Maureen Plowman Resthome)
Location: Date of Application:
Maureen Plowman Resthome (Browns Bay, Auckland) Feb. 3, 2011
Family Name (Last Name): Fruelda Given Names (Underline name used): Mark TeeJay Name you prefer to be called by: Mark Are you known by any other name(s)? N/A
Contact Details & telephone numbers
Contact Address: 5 Cassia Place, Sunnynook City: Northshore, auckland Home Phone No: Other Phone No. (If Any): 02102510263
Have you reached the current school leaving age (16 years)?
Hours available to work
Less than 10 hours per week 10 – 20 hours per week
(please tick box to indicate total hours available to work per week) 20 – 30 hours per week
30 – 40 hours per week
Evenings up to 23h00
Overnight 22h00 – 07h00
Are you prepared to work rostered shifts if required to do so? Are you prepared to work overtime if required? Are you available for relieving/casual shifts only? Are you prepared to work weekends if required to do so?
Yes Yes Yes Yes
/ No / No / No / No
Bupa Care Services Application for Employment
Page 1 of 9 Version3 : Feb 09
for the purposes of managing the employment relationship.Note: Purpose: Completing this form does not impose or imply any obligation on Bupa Care Services to employ you. Bupa Care Services Application for Employment Page 2 of 9 Version3 : Feb 09 . Under the Privacy Act 1993 you are entitled to access and request the correction of any personal information held by Bupa Care Services. This form collects personal information about you for the purpose of assessing your suitability for employment at Bupa Care Services and. Failure to provide all of the information requested may impair our ability to assess your suitability and compromise our ability to choose the right person for the position. if employed.
: Yes Yes Yes Yes Yes / No / No / No / No / No Expiry Date: Education List your highest levels of education. institution / school and year obtained: Philippine Regulation Commission. Cardiopulmonary Resuscitation (CPR) level 1 First Aid Training Advance Cardiac Support Clinical coaching for Dementia Manual Handling and Restraint minimization Drug Competency Health and Safety 1 Bupa Care Services Application for Employment Page 3 of 9 Version3 : Feb 09 . other than English? Qualifications Tagalog Do you have any other qualifications/certificates/licences/or attended any courses? (Please give details and submit copies of these with resume. 2008 Bachelor Science in Nursing – Arellano University (Philippines) .Legal work status ( tick the appropriate box) Are you … Legally entitled to work in New Zealand? A New Zealand Citizen A Permanent Resident (You must present your Passport with your Permanent Residency Visa attached) A holder of a current Work Permit (You must present your Passport with valid Work Permit) Health Practitioners only – Do you have a valid practising certificate for the position you have applied for? (Attach a copy to this form) Annual Practising Certificate No.Registered Nurse. Originals are to be sighted at interview stage so please ensure you take them with you). Nov. Batch 2008 Languages List any languages that you can hold an every day conversation in.
when can you start? Anytime Bupa Care Services Application for Employment Page 4 of 9 Version3 : Feb 09 .Availability If your application is successful.
10 40 Patients Care Address Odiongan. Romblon Philippines Staff Nurse Just for 6 mos. Browns Bay Northshore Healthcare Assistant (Team Leader) Want to transfer in different work environment Dates of employment Job Held Number of hours per week Reason for leaving Main Duties Assisting Residents in personal care and Activities of daily Living Previous Employer (List in date order starting with the most current job) Company Life Recruitement Agency 10 Dec.15 Apr. New Zealand Caregiver Casual employment Dates of employment Job Held Number of hours per week Reason for leaving Main Duties Assisiting the Residents in their Personal Care and Activities of daily living Previous Employer Company Romblon Provincial Hospital (Philippines) 15 Oct. 09 40 Patients Care Address Calatrava.2011 20-30 Address Auckland City. 09.3 2011 40 Address 2 valley road.Current Employer Company Maureen Plowman Resthome Feb. 09 – 1 oct. 2010 – 02 feb. Romblon Philippines Staff Nurse Need to go abroad Dates of employment Job Held Number of hours per week Reason for leaving Main Duties Previous Employer Company Calatrava Municipal Health office 1 Apr. contract Dates of employment Job Held Number of hours per week Reason for leaving Main Duties Bupa Care Services Application for Employment Page 5 of 9 Version3 : Feb 09 .
please detail: General All employees are subject to NZ Police vetting. Word of Mouth. partner. disability. Newspaper. and Paid all your fines. please detail: Bupa Care Services Application for Employment / No Page 6 of 9 Version3 : Feb 09 . Nursing Council of New Zealand. and Never been indefinitely disqualified from driving for driving offences involving alcohol or drugs.govt. Door Knocking) Trade me Advertisement………………………………………………………………. or relative or working here or elsewhere in the same industry? If yes. materials. where and when: Yes / No Yes / No Do you have secondary employment? If yes. reparation and Court costs. corrective training or borstal. you must have: • No convictions in the last seven years. You are not required to disclose convictions which meet the requirements of the Criminal Records (Clean Slate) Act 2004. Advertising.justice. provide details? Are you prepared to handle all products. home detention.nz\privacy\clean-slate. or equipment used in the industry? Do you have a current driver licence? If yes.Employment background Have you ever worked for Bupa Care Services or Guardian Health Care before? If yes. Do you consent to undergo a medical examination if you are offered employment? Yes / No Do you have/or have you had any medical or surgical condition. Do you have any criminal convictions in New Zealand or any other country? Yes / No (Note:. Yes If yes. mental health disorder or accident compensation (ACC) injury which may be aggravated by the job or affect your ability to work for Bupa Care Services in the particular position you applied for? Yes If yes. Walk In. and Never been ordered by the Court to go to hospital or a secure facility (instead of a sentence) due to your mental condition. Are you awaiting the hearing of charges in a civil or criminal court of law? Yes / No / No Have you been or are you currently subject to or awaiting the outcome of any investigation or a complaint by your professional body e. the offer may be made subject to your obtaining a full medical clearance (by completion of medical examination) to assess your fitness for the job for which you are applying.g.html).*) *To qualify for not disclosing your criminal convictions. what class? Yes Yes / No / No International Liscence N02-09-003025 Yes Yes / No / No Driver Licence No. provide details? How did you hear about this position? (eg. Medical If you are offered employment. and • • • • No convictions of a “specified offence” (this includes sexual offending against children or young people – for a full list see www. and • Never been sentenced to prison. Referred by friend. Internet.: Do you have any demerit points or endorsements? Do you have a spouse.
Bupa Care Services Application for Employment Page 7 of 9 Version3 : Feb 09 .
I understand that the information received by the Company is supplied in confidence as evaluative material and will not be disclosed to me. Gloves.Medical Are you vaccinated against: Hepatitis A Hepatitis B Have you had a flu vaccination this year? Have you been working in a health facility overseas in the last 6 months or in a NZ health facility with MRSA outbreak? Yes Yes Yes Yes / No / No / unknown / unknown / No / No / No Have you been in contact with any infectious illnesses within the last 6 months? Yes eg Tuberculosis (TB). 2011 Bupa Care Services Application for Employment Page 8 of 9 Version3 : Feb 09 .g. Hepatitis? Do you have any condition that would prevent you from wearing the necessary protective clothing? e. closed shoes. address and telephone numbers of at least two managers and/or supervisors including your last place of employment. steel capped shoes etc. Signed Date: 31 Oct. Yes / No Referees Name Position Address Give name. Carol Maharaj Nurse Maureen Plowman Resthome Name Position Address Michelle Preston Service Manager Life Recruitement Agency Office number Mobile number E-mail 0211610552 Office number Mobile number E-mail 354-3202 0212888703 Reference consent I Mark Tee Jay Fruelda consent to the above Bupa Care Services seeking verbal or written references on a confidential basis from my referees about me. Scabies. Ms. and authorise any other information sought to be released for the purposes of ascertaining my suitability for the position for which I am applying. hearing protection. masks.
is conditional on my obtaining a full medical certificate and / or police clearance certificate if required and requested by Bupa Care Services. Mark TEEJAY FRUELDA (full name) declare that to the best of my knowledge the information provided in this application and in any resume or CV is accurate and I understand that if any false or misleading information is given. I further understand that any offer of employment if made. or if I am employed. my employment may be terminated. I will not be employed.Declaration I. Signed: Date: 31-10-11 Bupa Care Services Application for Employment Page 9 of 9 Version3 : Feb 09 . or any material fact suppressed.
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