PERSONAL INFORMATION
Aegis Care Employment Application
Name:
*
First Name
Last Name
Phone Number:
*
-
Area Code
Phone Number
E-mail Address:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you eligible to work in Canada?
*
Yes
No
Are 18 years if age or older?
*
Yes
No
If yes, Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
AVAILABILITY AND RATE
What position are you applying for?
*
Registered Nurse (RN)
Registered Practical Nurse (RPN)
Personal Support Worker (PSW)
Resident Care Aide (RCA)
Advanced Foot Care Nurse (AFCN)
Dietary Aide
When are you available to start?
*
How did you hear about this position?
*
Zip Recruiter
Indeed
LinkedIn
Facebook
Twitter
Craigslist
Hirerology
Other
Employment Preference
*
Full-time
Part-Time
Casual
Shift Preferred
*
Days
Afternoon
Evenings
Nights
Overnights
Expected pay rate (per/hour)
WORK EXPERIENCE
List the 3 Most Recent
Rows
1
2
3
Employer
Full Address
Name of Immediate Supervisor
Phone Number
Email Address
Date of Employment
Job Title & Duties
Pay/Salary
Reason for Leaving
EDUCATION
Rows
Institution, City & Country
Years Attended
Degree/Diploma/Major
Post-Secondary (College/University)
High School/Secondary School
Other
Questions (Please pick Yes or No)
*
Rows
Pick One
Do you have 6 months experience in your profession?
Yes
No
Do you have a valid Ontario Class G Drivers License?
Yes
No
Do you own a vehicle or have access to reliable transportation?
Yes
No
Are you a member of any professional associations? (RNAO, RPNA, CNA)
Yes
No
Do you have CPR-First Aid? Or are you willing to obtain at your own expense?
Yes
No
SKILLS AND TRAINING
Please check all that apply
Medical/Surgical
Maternal
Pediatrics
Oncology
Orthopedics
Ministry of Labour Obligations Training
Ministry of Health Abuse and Aggression
Crisis Prevention Intervention Training (CPI)
Whistle Blowing
WHMIS
Rehab
Neurology
Radiology
Surge Training
Life Training
Safety Training
References
Please list two (2) references that are familiar with your work life.
Reference 1
Name:
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Years Known:
*
Reference 2
Name:
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Years Known:
*
Training or Certifications:
Disclaimer:
By signing, I hereby certify that the above information is correct. I understand that falsification of this information may prevent me from being hired or lead to my dismissal, if hired. I also provide consent for former employers to be contacted regarding work records, for my professional references to be called, and a criminal background check to be conducted on my profile. I further attest that I have not committed, been convicted of, nor prosecuted for any criminal offense.
Signature
*
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Upload Resume:
*
Upload a File
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Please verify that you are human
*
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