Register your details

Register your details

Enter your details into the form below and click the Update My Details button to register your details.

Once you have saved these details you can then upload your supporting documents and submit your application for the selected vacancy.

Items marked with * are required.

Login Details

Enter a User Name and Password.

User Name (Max 100 characters)
Email Address
Retype Email
Password (Numbers and letters only)
Confirm Password
Personal Details
Surname / Family Name
Given Names
Preferred Name
Are there any other names that you may be known by?
  If yes, please list (please indicate maiden names)
Contact Details
Postal Address
Post Code
Work Status Within New Zealand
Are you a New Zealand or Australian citizen?
If not, please complete the remainder of this section:
What is your passport number? Please note this is used for verification of immigration status only.
If you are not a New Zealand or Australian citizen, do you hold a New Zealand residency permit?
Do you hold a valid NZ work visa/permit appropriate for the job you are applying for?
If not, have you commenced the work visa/application process?
Visa Details
If you do hold a valid New Zealand work/visa permit please provide details and conditions:
Visa Type
Conditions of Visa
Work Visa/Permit No.
Expiry Date

Note: Please include a copy of your visa/permit with your application
Accepted file types are .pdf (Acrobat), .doc (Word 97-2003), .docx (Word 2007+)

Attach Visa Documents
Previous Employment with Southern District Health Board
Are you a current Southern District Health Board employee or have you ever been an employee of Southern DHB and/or its predecessors?

If yes, please provide details including dates:
(We may refer back to our records of any previous employment in considering this application)

Were you known by any other name while at Southern DHB and/or its predecessors?
Are you currently employed by an agency and engaged by the Southern DHB in a temporary capacity?
If yes, please indicate which agency
Authority to Practice (if applicable)
Do you have a current New Zealand or Overseas Practising Certificate / Registration?
Date Note: To select the date click the calendar button next to the date field, you cannot type directly into these date fields. The date format must be dd/mm/yyyy e.g. 31/12/2021
Registration Type Date of Registration Country of Registration Registration Number
Staff Requiring Occupational Registration
Has your regulatory authority or similar professional body taken any disciplinary action against you in the past, or is there any action pending by your regulatory authority / professional body, which may impact on your ability to carry out the duties required in the position you are applying for?
If yes, please provide details:
Professional Membership
Are you a member of any Society/Professional Association(s)?
If yes, please provide details:
Fitness to Undertake Work

The purpose of gathering the following information is to enable Southern DHB to determine whether you have any medical condition, injury or impairment which may affect your ability to perform the required work. It will also identify areas where there could be health and safety risk to you, or others relating to such condition, previous injury or impairment.

Have you ever had significant time off work as a result of any physical or mental illness, injury or infection that may affect your ability to perform the job applied for?
If yes, please specify details (including estimate of time off, year of occurrence and reason).
Do you know of any physical or mental illness, injury, (including chemical sensitivities, skin problems, allergies, hearing or eyesight difficulties) infection, addiction, condition or anything else that may effect your ability to undertake, or be aggravated by, the role that you have applied for, or your employment in general, or might affect you attending work regularly?
If yes, please specify details:
Is there anything else you know of that could affect your ability to be employed in the role you have applied for?
If yes, please specify details:
Are there any disability needs, ongoing or pending treatment and needs or restrictions regarding your ability to work, which will require accommodation if you are successful with your application?
If yes, please specify details:

Note: A prior gradual process or musculoskeletal injury may not prevent you from working at the DHB, although injury documentation may be requested. You may also be required to provide evidence of your immunisation status before commencement.

Other Relevant Information
Driver Licence
Do you hold a driver licence that currently allows you to drive, and is valid for use in New Zealand?
Indicate licence type:
If yes, please state the class(es) of the driver license you hold.
Criminal Convictions

All Southern DHB staff are required to satisfactorily complete either police vetting or a criminal conviction check.  For positions with budgetary responsibility we will also conduct a credit check through a 3rd party, the result of which will be part of our decision making for your suitability for the position.

NOTE: You are not required to disclose any convictions that you are eligible to conceal under the provisions of the Criminal Records (Clean Slate) Act 2004.  It is your responsibility to determine if you are eligible to conceal any conviction.

To find if you may be eligible please go to this website: Justice Department About The Clean Slate Act 2004

Have you any criminal convictions, in New Zealand or overseas?
If yes, please specify details:
Have you any actions pending which could result in criminal convictions?
If yes, please specify details:

The DHB will require a pre-employment criminal record check and is also required to perform safety checks in terms of the Children's Act 2014  for roles where children's workers are to be appointed. Do you consent to the District Health Board undertaking such a criminal record checks?

(This may include getting police vetting reports from other countries for overseas candidates).
Please Note: If you are not prepared to consent, do not complete and submit your application.

Do you have any obligations or commitments that may affect your ability to commence employment if offered a position?
If yes, please provide details:
Statistical Data

Ministry of Health requires District Health Board's to provide statistical data on applicants.
This information is not provided to the hiring manager and is not used as part of the assessment for the suitability for the position. It is used as statistical data only.

Please indicate the description which best describes your ethnic group.
Select Ethnicity
If you consider you have a long-term disability lasting 6 months or more that restricts you in performing every day activities, please tick the relevant box(s) below. Relevant definitions are included below.

Disability Definitions
Sensory disability

Hearing - you have difficulty or cannot hear what is said in a conversation with another person and/or a conversation with at least 3 other people.
Seeing - you have difficulty seeing or cannot read ordinary newsprint and/or the face of someone across a room, even when wearing corrective lenses.

Physical disability

Mobility - you find it difficult to or cannot walk about 350 metres without resting, walk up or down a flight of stairs, carry an object as heavy as 5 kilograms for a 10 metre distance, move from room to room, or stand for longer than 20 minutes.
Agility - you find it difficult to or cannot bend over to pick something off the floor, dress or undress yourself, cut your own toenails, grasp or handle small objects like scissors, reach in any direction, cut your own food, or get yourself out of bed.

Intellectual disability You need support or help from organisations like IHC or People First, or you have been to a special school or receive special education because of an intellectual impairment.
Psychiatric / psychological disability Because of a long-term emotional, psychological or psychiatric condition, you have difficulty with or are stopped from doing everyday activities that other people your age can usually do, from communicating, from mixing with others or socialising.
Other disability You have difficulty speaking or being understood, or you have a disability not included above.
Update My Details
I certify that to the best of my knowledge the answers given and any documents in respect of this application are true and correct. I understand that any position I may be offered will be based on the answers and the details I have provided and if any false information has been given or material fact suppressed, I may not be accepted, or if I am employed, I may be dismissed.

Please note you will receive confirmation of successfully completing this registration form to the email address you provide above.

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