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
What is your highest level of certification in Alberta?
*
Registered Health Care Aide
Non-Registered Health Care Aide
LPN Student - Finished 1st Year
RN Student - Finished 2nd Year
Community Support Worker
Personal Support Worker
Companion
Internationally Educated Nurse
Other
Are you registered in the Alberta Health Care Aide Directory?
*
Yes
No
HCA Directory Number
Applicant Postal Code
*
What side of the city do you live in?
*
Central Edmonton
South Edmonton
East Edmonton
West Edmonton
North Edmonton
Downtown
St. Albert
Sherwood Park
Leduc
Spruce Grove
Stony Plain
North East Area of Edmonton
North West Area of 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
Availability: Please list your availability for each day of the week
*
Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday:
Ex. Monday: 7 AM to 7 PM
Unavailability: Please list the days and times that you are NOT available to work (due to another job, personal, child care, etc.)
*
Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday:
Ex. Monday: 7 PM to Midnight
Are you currently working or in school?
*
Working in facility
Working other job
School (Full-Time)
School (Part-Time)
Other
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
What is your current hourly rate of pay?
Our starting wage is $19.00/hr if you are registered on the HCA Directory and $18.00/hr if you are NOT on the HCA directory. Is this acceptable for you?
*
Yes
No
Other
Do you speak any other language(s) in addition to English?
*
Are you able to work with pets?
*
Number of hours wanted per week?
*
If hired, when would you be available to start working?
*
-
Month
-
Day
Year
Date
Resume
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Recruiter Notes
Which clients could this applicant be a fit for?
Submit
Should be Empty: