Please enter the requested details in the form below. Include any experience you have in the appropriate industries. Please include full details regarding your work background. If none of the registration form on the second page applies to you please e-mail your CV to office@mainlandpersonnel.co.nz We thank you in advance for your register of interest.

Please enter your Details; * denotes required information.
Title:	Mr Miss Mrs
* Your Full Name:
* Address:
* Suburb:
Postal Address: (if different from above)
* City:
* Country:
* Home Phone
Work Phone:
* E-Mail:

Citizenship:
NZ Citizen	Permanent NZ Resident
Hold NZ Work Permit	Require NZ Work Permit

Do you have any convictions against the law?
Yes	No
Please enter details below

Health Details:
Have You Had;
Asthma	Yes	No		Bronchitis	Yes	No
Dermatitis	Yes	No		Eczema	Yes	No
Hernia	Yes	No		Back Injury/Strain	Yes	No
ACC Injury	Yes	No		Date of Injury
				Details of ACC Injury
Earache/Deafness	Yes	No		Skin Infections	Yes	No
High Blood Pressure	Yes	No		Heart Problems	Yes	No
Diabetes	Yes	No		Any Allergies	Yes	No
Blackouts/Seizures	Yes	No		Stress	Yes	No
Mental Illness	Yes	No		Alcohol or Drug Abuse	Yes	No

Are you taking drugs or medicine?
Yes	No	Please enter details;
How many days absence due to sickness have you had in the last 12 months?
Give details of any serious accident/illness/disability in the last 5 years.
Please give details about any other ailments or diseases which may affect your performance, or which the company should know about.