Careers Form

* = Required Information

Application for Employment

Date

Name

Last *

First *

Middle *

Address

Street

City

State/Province

ZIP/Postal Code

Telephone #

Cell Phone #

E-Mail Adress *

Referred to us by

Position(s) applied for

Caregiver

Nursing

Other

Date available

Type of employment desired

Full-Time

Part-Time

Casual

Please specify Days and Hours

If currently employed, may we contact your employer?

Yes

Rate of Pay Expected

Is there a specific reason you are applying for employment at this company?

Yes

Please briefly outline the reason

Are you legally eligible for employment in this country?

Yes

Are you available to work overtime if required?

Yes

Have you been employed at this company before?

Yes

When?

What Location?

Do you have any friends or family employed at this location?

Yes

Have you been convicted of a crime in the last seven (7) years?

Yes

Please explain CONVICTION WILL NOT NECESSARILY BE A DISQUALIFICATION FOR EMPLOYMENT.

If considered for hiring, will you agree to provide a criminal background check?

Yes

If considered for hiring, will you agree to provide a drivers abstract?

Yes

EDUCATIONAL BACKGROUND

List previous three (3) educational institutions attended, beginning with the most recent.

School

City, State/Province

Graduated?

Yes

Degree(s)/Diploma(s) Earned

School

City, State/Province

Graduated?

Yes

Degree(s)/Diploma(s) Earned

School

City, State/Province

Graduated?

Yes

Degree(s)/Diploma(s) Earned

What Nursing or relevant designations, licenses or registrations if any, do you possess?

Type

Date of Most Recent Registration

Valid in State/Province ?

Yes

Do you have the following:

CPR

Yes

Last Certified

First Aid

Yes

Last Certified

WHMIS

Yes

Last Certified

EMPLOYMENT BACKGROUND

Provide the following information beginning with the most recent employer.

Employer

Telephone

Address

Job Title

Immediate Supervisor

Title

Phone Number

Dates Employed From

Dates Employed To

Hourly Rates/ Salary

Starting

Per

Final

Per

Reason for Leaving

Summarize the type of work performed and Job Responsibilities

May we contact for reference?

Yes

Later

Employer

Telephone

Address

Job Title

Immediate Supervisor

Title

Phone Number

Dates Employed From

Dates Employed To

Hourly Rates/ Salary

Starting

Per

Final

Per

Reason for Leaving

Summarize the type of work performed and Job Responsibilities

May we contact for reference?

Yes

Later

Employer

Telephone

Address

Job Title

Immediate Supervisor

Title

Phone Number

Dates Employed From

Dates Employed To

Hourly Rates/ Salary

Starting

Per

Final

Per

Reason for Leaving

Summarize the type of work performed and Job Responsibilities

May we contact for reference?

Yes

Later

Employer

Telephone

Address

Job Title

Immediate Supervisor

Title

Phone Number

Dates Employed From

Dates Employed To

Hourly Rates/ Salary

Starting

Per

Final

Per

Reason for Leaving

Summarize the type of work performed and Job Responsibilities

May we contact for reference?

Yes

Later

REFERENCES

List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).

Name

Relationship

Years Acquainted

Phone Number

Name

Relationship

Years Acquainted

Phone Number

Name

Relationship

Years Acquainted

Phone Number

I certify that all the information I have provided is true, complete and correct.

The information contained within this application or any cover letter or resume attached is not shared with any third parties. The information is used by the employer only as an aid in the hiring decision making process. The applicant, by signing the application gives the employer consent to collect the information contained herein and use for the purpose specified.

I authorize this company to investigate all statements contained on this application. I understand that any misrepresentation or omission of facts called for is cause for immediate disqualification and/or if employed, immediate dismissal.

I understand that if I am hired, I will be required to provide criminal background check at my cost, proof of identity and legal authority to work in the United States, proof of certifications or educational qualifications, and a drivers abstract (if applicable).

Furthermore, I understand and agree that if employed, I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same rights to terminate my employment at any time, with or without prior notice, except as may be required by law. This application does not in any way constitute an agreement or contract for employment.

Full name

Date