Online Referral

DETAILS

Name *

Address

Telephone

Mobile

Email *

Gender *

MaleFemale

Date of Birth

Ethnicity

Self

Other Agency

Suport Worker

Telephone

WINZ Number

IRD Number

Case Manager

Case Manager Telephone

Case Manager Email

Receiving Work and Income Benefit

YesNo

Type of benefit

Disabilities or barriers to employment

Transport

CarBicycleBusOther

License

NoneRestrictedFull

License Classes

12456FDGWTR

Preferred working location

Preferred working hours

Do you have a CV

Yes (If yes, please bring with you to your first appointment)No

PLEASE NOTE

Provision of WORKSTAR Supported Employment Services is conditional upon acceptance of the following terms:-

That WORKSTAR will continue to provide support for a minimum of 6 months after successfully gaining employment through their services.
That WORKSTAR (under the provisions of the Privacy Act 1993 and the Health Information Privacy Code 1994) will be authorized to collect or disclose any information which will assist in the delivery of service.
Declaration of Criminal Convictions/charges pending
Agreement to abide by the WORKSTAR Code of Conduct for Clients

WORKSTAR operates a zero tolerance to violence policy, any acts of aggression will result in you being asked to leave WORKSTAR immediately