"New Zealand Fee Agreement Permanent Placement"
Application Form – New Zealand (All personal details are held in the strictest confidence, Intern Options Limited is a registered data controller with Information Commissioner’s Office for more information visit www.ico.gov.uk) Personal Information (Please print clearly using blue/ black pen) Family name: ____________________ First and middle names: ____________________________________ (Please write exact name as it is in Passport) Date of birth ………/………/……… Gender: Male / Female (Day Month Year) Marital Status: _____________________ Nationality: _____________________ Permanent address: ___________________________________________________________________ ____________________________________________________________________________________ Email address: _____________________@_____________________ Tel ________________________ Emergency contact: Name: __________________________________________ Relationship to you: _____________________ Tel: ________________________ Email address: _____________________@_____________________ Ideal start date (month): ________________ How long available for: ______________ months Any disability (Bad back, hayfever etc), special food requirements? _________________________________ ___________________________________________________________________________________________ Have you a prison or police record? Yes No If Yes details ________________________________________________________________________________ ___________________________________________________________________________________________ Leisure interests_____________________________________________________________________________ Height ____________ Weight ____________ Do you hold Full Driver’s License? Yes No 1 Education and Qualifications Ag-College/ University: Dates from/to: Qualifications obtained: ________________________________________________________________________________________ ________________________________________________________________________________________ Lecturer’s name: _____________________________ Lecturer’s contact number:_____________________ Lecturer’s email ______________________@___________________ Are you from a farming family Yes / No - If so please give details of home farm and your involvement ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ I have enclosed references Yes No Payment A deposit of £300 is required with your completed application form before processing will begin. £180 of this deposit is non-refundable immediately, £300 is non-refundable once the placement has been confirmed and communicated to you via email or post. If we cannot find you a placement then we will refund your deposit in full. Payment is accepted by either cheque or bank transfer. Please don’t send cash with your application. Cheque – Please make cheque payable to Intern Options Limited. Bank Transfer – Intern Options bank details can be sent on request. A final payment of £350 is payable to Intern Options within 30 days of receiving your letter/ email acceptance for this programme. 2 Applicant Declaration As a prospective participant in the Intern Options New Zealand Programme, I agree to abide by all rules and conditions of our partner company, Marvin Farm Services. I understand that Intern Options and Marvin Farms are in no way financially responsible for me in the case of accident or emergency and that it is my responsibility to ensure that I have appropriate travel and health insurance. I give the authority to contact previous employers for work and character references. All the information we receive will be treated in the strictest confidence. I understand that some of the information on this form and its support documents may be provided to other parties involved in the approval of this placement or to those who are making arrangements relating to this application. I confirm that all statements in this form as well as on the support documents are true and complete, and that I have carefully read and understood the conditions of this programme. Signature of applicant: Date: ………………………………………………. ……………………………………… By signing this agreement you agree to the terms and conditions stipulated within, any false information given to Intern Options Limited, Marvin Farm Services or New Zealand Immigration could result in your internship being cancelled and deposit or full fee withheld. Completed applications and programme queries should be addressed to: Intern Options 159-161 Temple Chambers 3-7 Temple Avenue EC4Y 0DA London +44 (0) 207 353 7699 email@example.com www.InternOptions.com 3