APPLICATION FOR EMPLOYMENT

Position and location

Position Applied For:

Caregiver/Healthcare Assistant

Do you have any previous experience for the role you have applied for? If yes, please detail:

Yes

/ No

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

Name
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

Age
Have you reached the current school leaving age (16 years)?

Yes

/ No

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

Weekends

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

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Note: Purpose:

Completing this form does not impose or imply any obligation on Bupa Care Services to employ you. This form collects personal information about you for the purpose of assessing your suitability for employment at Bupa Care Services and, if employed, for the purposes of managing the employment relationship. 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. Under the Privacy Act 1993 you are entitled to access and request the correction of any personal information held by Bupa Care Services.

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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.:

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- Registered Nurse, Nov. 2008 Bachelor Science in Nursing Arellano University (Philippines) , Batch 2008

Languages
List any languages that you can hold an every day conversation in, 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. Originals are to be sighted at interview stage so please ensure you take them with you). 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

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Availability
If your application is successful, when can you start?

Anytime

Bupa Care Services Application for Employment

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Current Employer
Company

Maureen Plowman Resthome Feb.3 2011 40

Address

2 valley road, 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. 2010 02 feb.2011 20-30

Address

Auckland City, 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- 15 Apr. 10 40 Patients Care

Address

Odiongan, 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. 09 1 oct. 09 40 Patients Care

Address

Calatrava, Romblon Philippines Staff Nurse Just for 6 mos. contract

Dates of employment

Job Held

Number of hours per week

Reason for leaving

Main Duties

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Employment background
Have you ever worked for Bupa Care Services or Guardian Health Care before? If yes, where and when:

Yes

/ No

Yes / No

Do you have secondary employment? If yes, please detail:

General All employees are subject to NZ Police vetting.

Do you have any criminal convictions in New Zealand or any other country? Yes / No (Note:. You are not required to disclose convictions which meet the requirements of the Criminal Records (Clean Slate) Act 2004.*) *To qualify for not disclosing your criminal convictions, you must have: No convictions in the last seven years; and Never been sentenced to prison, home detention, corrective training or borstal; and

No convictions of a specified offence (this includes sexual offending against children or young people for a full list see www.justice.govt.nz\privacy\clean-slate.html); and Never been ordered by the Court to go to hospital or a secure facility (instead of a sentence) due to your mental condition; and Paid all your fines, reparation and Court costs; and Never been indefinitely disqualified from driving for driving offences involving alcohol or drugs.

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.g. Nursing Council of New Zealand. Yes If yes, provide details?

Are you prepared to handle all products, materials, or equipment used in the industry? Do you have a current driver licence? If yes, what class?

Yes Yes

/ No / No

International Liscence N02-09-003025 Yes Yes / No / No

Driver Licence No.:

Do you have any demerit points or endorsements? Do you have a spouse, partner, or relative or working here or elsewhere in the same industry? If yes, provide details?

How did you hear about this position? (eg. Word of Mouth, Referred by friend, Advertising, Newspaper, Internet, Walk In, Door Knocking)

Trade me Advertisement.

Medical
If you are offered employment, 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. 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, disability, 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, please detail:

Bupa Care Services Application for Employment

/ No

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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), Scabies, Hepatitis?

Do you have any condition that would prevent you from wearing the necessary protective clothing? e.g. Gloves, masks, closed shoes, hearing protection, steel capped shoes etc. Yes / No

Referees
Name Position Address

Give name, address and telephone numbers of at least two managers and/or supervisors including your last place of employment.

Ms. 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, and authorise any other information sought to be released for the purposes of ascertaining my suitability for the position for which I am applying. I understand that the information received by the Company is supplied in confidence as evaluative material and will not be disclosed to me.

Signed

Date: 31 Oct. 2011

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Declaration

I, 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, or any material fact suppressed, I will not be employed, or if I am employed, my employment may be terminated. I further understand that any offer of employment if made, is conditional on my obtaining a full medical certificate and / or police clearance certificate if required and requested by Bupa Care Services.

Signed:

Date:

31-10-11

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