2. Applicant Form

Harmony HCA Applicant Form

Thank you for taking the time to fill in this form, it should only take you about 5 minutes and it will help us determine if there is a client match. Only Candidates who complete the form in full will be considered for an interview. Please note that applicant completed forms are kept on file for three months. Please contact our office if you would like to be removed from the applicant list and you would need to reapply after three months to be added to the applicant list again.
Applicant First Name *
Applicant Last Name *
Applicant Mobile Phone Number (Personal) *
Please enter a valid phone number.
Applicant Email (Personal) *
example@example.com
Are you a Certified Health Care Aide? *

Yes No LPN Student - Finished 1st Year RN Student - Finished 2nd Year Community Support Worker Personal Support Worker Other
What side of the city do you live in? *

Central Edmonton North Edmonton South Edmonton East Edmonton West Edmonton Downtown St. Albert Sherwood Park Leduc North East Edmonton North West Edmonton Other
Driving and Transportation *

Licence and Vehicle Licence and No Vehicle No Licence (Use the bus)
If you drive, are you ok with driving clients in your vehicle?

Yes No
Do you have a Graduated Driver's Licence (GDL) ?

Yes No
What is your current AVAILABILITY? *

Open Availability Days Evenings Nights Weekends Other
Are you registered in the HCA Directory? *

Yes No
Do you have the following certification up to date? *

Criminal Record Check (within 12 months) First Aide/CPR Valid Drivers License Vehicle Insurance (2 Million Dollar Liability) and Registration Covid-19 #1 Vaccination Covid-19 #2 Vaccination Other
Are you currently working in a facility? *

Yes No
Starting wage is $18.00/hr is this acceptable for you? *

Yes No Other
Do you speak any other language(s) in addition to English? *
If hired, when would you be available to start working? *

Month Day Year
Date
Should be Empty:

Harmony HCA Applicant Form