EXPRESSION OF INTEREST FORM
PERSONAL DETAILS
Last Name
LESA
First Name
FALE
Preferred Name (if different from above)
Postal Address
Suburb
Town/City
Post Code
Daytime Contact Number
Mobile Phone Number
Email Address
Education and professional / associations information.
CURRENT EMPLOYER (IF APPLICABLE)
Employer:
N/A SELF-EMPLOYED.
Position held:
Starting date:
Main responsibilities:
Qualification /
Institution /
Date obtained / Current
Membership
Association
SEE RESUME.
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RIGHT TO WORK
Are you legally entitled to work in New
Zealand?
(i.e., as a citizen/permanent resident/holder
of a current work permit)
Do you have a current practising certificate or
professional accreditation
If yes please advise what certificate or
accreditation you hold
PERSONAL ATTRIBUTES – What you think you have that will add value to the CAC role
As a Justice of the Peace and an experienced director of the crown, I take integrity
very seriously. As chair of the personnel committee, I managed disciplinary hearings
at
for over ten years. In my capacity as deputy chairman of
the
, I managed concession applications on behalf of
. I know the importance of process and the independence of those responsible
for every decision. I am a native Samoan speaker raised in
and
would have empathy for underserved constituencies. I was appointed by
as a
. I have also helped organise
iconic Auckland events
and
. I work closely with
local
communities as well as
The profile of the kiwi
homeowner and tenant is changing and CAC must reflect these changes in order to
foster a high degree of trust and confidence with the general public and other key
stakeholders. I honour my commitment to the Treaty of Waitangi in my fluency of Te
Reo Māori, my recent graduation from
, serving on the stakeholders committee at
for the
and my past experience
with
and
.
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MEDICAL CONDITIONS
Have you had an injury, disability or illness
that could be further aggravated by any tasks
you may be required to perform?
Note: this information is required to assist us
in meeting our obligations to provide a safe
workplace for staff. Declaration of a medical
condition will not rule you out of
consideration.
BACKGROUND CHECKS
Do you currently have any criminal charges
pending or are you awaiting the hearing of
any charges (whether civil or criminal)?
Are you under investigation for any potentially
criminal matter or any other breach of
legislation (including any investigation or
charges laid by a professional disciplinary
body)?
Have you been granted a Diversion by the
Court?
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Have you been convicted of any criminal or
other offence, where the conviction was more
than 7 years ago, and it does not meet the
criteria for withholding disclosure as outlined
above?
Have you been convicted of any criminal or
other offence within the last 7 years?
Have you ever taken a personal grievance
against a previous employer?
In the previous three years, have you been
the subject of a serious misconduct
investigation, concluded and upheld or
currently under investigation, within a public
service or Crown entity employer?
REFEREES
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Please indicate the name, telephone numbers and email address of anyone you would be happy
for Real Estate Authority (or its representative) to contact about your suitability for the position.
Ideally at your current manager and if you have had any other CAC type appointments the person
you reported to.
Name
Contact Number(s) / Email Address
1
2
0
3
PRE-ENGAGEMENT SCREENING
As part of our pre-engagement screening process, certain checks may be required to be
undertaken e.g. criminal, credit and/or qualifications. If so, you will be asked to complete
further documentation for this.
Declaration of a conflict of interest does not necessarily exclude opportunities within REA. The
following question is to ensure we identify any conflicts whether actual, perceived or potential.
Do you have any private or professional interests or associations that have the potential to
impact on your ability to carry out, or be seen to carry out, your activities impersonally and in
REA’s interest?
If yes, please specify your private / professional interest and /or associations.
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HEALTH AND SAFETY REQUIREMENTS
Declarations of a medical condition does not necessarily exclude opportunities with REA. The
following questions are to ensure you can safely carry out the position:
1. Are you aware of any current or former health related conditions that would affect your
performance or ability to carry out the duties and responsibilities of the position or that
may be aggravated or further contributed to by the work of the position for which you are
applying?
2. Do you currently have or have you ever had (including anything that may have resulted in
a claim for compensation for incapacity) any gradual problem, disease, infection or
symptom of occupational overuse syndrome (“OOS”) such as but not limited to aches,
pains, numbness, tingly or burning sensations that may affect your ability to carry out the
role?
3. If you have indicated a medical or health related condition that could affect your ability to
carry out your job, please indicate whether you would be prepared to undergo a medical
examination by a doctor nominated by REA (and at REA’s expense) to determine your
ability to perform your job prior to us making a decision about your application.
4. If you are currently suffering or have suffered in the past from injury or illness, are there
any specific services or facilities which we could provide to enable you to carry out the
work duties safely?
5. Are you earning, or do you anticipate that you will earn income from secondary
employment?
AUTHORITY AND DECLARATION
▪
I consent to the Real Estate Authority seeking verbal or written information about me from
my listed referees and authorise the release of this information to the panel. This
information is provided on the understanding that it is evaluative material in terms of
Sections 29(1) and 29(3) of the Privacy Act 1993 and will not be disclosed to me unless the
referee gives their specific permission.
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▪
I consent to the Real Estate Authority conducting all pre-engagement and background
checks.
▪
I consent to the disclosure to the Real Estate Authority of whether I have been subject to a
conduct or serious misconduct investigation, either concluded and upheld or currently
under investigation, from all present or previous professional bodies.
▪
I agree to participate in any medical screening to further determine my suitability for the
position applied for, if requested by the Real Estate Authority.
▪
I declare that to the best of my knowledge the information in this Form is complete and
correct and I understand that if I give any incomplete, false or deliberately misleading
information, or suppress any material fact in the process, I may not be accepted or if I am
employed, my contract may be terminated.
▪
All personal information collected will be stored and used in accordance with the Privacy Act
2020.
Signature
(sign/type)
Date
11/10/21
EQUAL OPPORTUNITIES (EO)
The Real Estate Authority is committed to EO, understanding the needs of their people and the
elimination of all forms of unfair discrimination.
To assist us in measuring our progress towards achieving our EO goals we would appreciate
you taking the time to complete the following form. This provides us with useful information
about staffing patterns and trends for different groups of people.
The information will not be used for selection purposes. The information is confidential and
used for reporting purposes only. Please tick what applies to you.
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GENDER
ETHNICITY
NZ Maori
Indian
NZ European/Pakeha
Other Asian
Other (please
Other European
specify)
Chinese
Prefer not to declare
DISABILITY
Do you have a disability of any kind that restricts you in performing everyday activities, and
which is long-term (lasting 6 months or more)?
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