Form

Application for Employment
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referred By:
Position(s) Applying For:
Date Available To Start:

MonthDayYear
Date
Type of Employment Desired
Please Specify Days & Hours
Please Specify Days & Hours
If Currently Employed, May We Contact Your Employer:
Rate of Pay Expected:
Rate of Pay Expected:
Is there a specific reason you are applying for employment at this company?
Are you legally eligible for employment in this country?

YesNo
Are you available to work overtime if required?

YesNo
Have you applied with this company before?

YesNo
Have you been employed at this company before?

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

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

YesNo
If yes, please explain:
If considered for hiring, will you agree to provide a criminal background check?

YesNo
If considered for hiring, will you agree to provide a driver's abstract?

YesNo
EDUCATIONAL BACKGROUND

List previous three (3) educational institutions attended, beginning with the most recent.
SCHOOL:   Type a label
CITY, STATE/PROVINCE:   Street Address      City   State
GRADUATED:   Yes   No
DEGREE(s)/DIPLOMA(s):   Type a label

SCHOOL:
CITY, STATE/PROVINCE:
GRADUATED:
DEGREE(s)/DIPLOMA(s):

SCHOOL:   Type a label
CITY, STATE/PROVINCE:   Street Address      City   State
GRADUATED:   Yes   No
DEGREE(s)/DIPLOMA(s):   Type a label
What Nursing or relevant designations, licenses or registrations if any, do you possess?

Type:
Date of Most Recent Registration:   Date
Valid in State/Province:    Yes   No

Type:
Date of Most Recent Registration:   Date
Valid in State/Province:    Yes   No
Do you have the following:

CPR:   Yes   No   Last Certified:   Date
First Aid:   Yes   No   Last Certified:
WHMIS:   Yes   No   Last Certified:   Date
PLEASE ANSWER THE FOLLOWING QUESTIONS
What do you think is the most difficult part of nursing or customer service work?
What was the best job you ever had and why?
What was your least favorite job and what did you dislike about it?
Think of the BEST supervisor you have ever had, what characteristics made that person a good manager?
Think of the WORST supervisor you have ever had, what characteristics made that person a poor manager?
How will you be able to contribute to providing seniors with high quality care?
Imagine you have been on your feet and working hard all day. A customer that you have been dealing with is rude and impatient, what do you do?
EMPLOYMENT BACKGROUND

Provide the following information beginning with the most recent employer.
EMPLOYER:
TELEPHONE:   Area Code   Phone Number
ADDRESS:   Street Address      City   State
JOB TITLE:
SUPERVISOR'S NAME:   First Name   Last Name
REASON FOR LEAVING:
HOURLY RATE/SALARY:
MAY WE CONTACT:   Yes   No

EMPLOYER:
TELEPHONE:
ADDRESS:
JOB TITLE:
SUPERVISOR'S NAME:
REASON FOR LEAVING:
HOURLY RATE/SALARY:
MAY WE CONTACT:

EMPLOYER:
TELEPHONE:   Area Code   Phone Number
ADDRESS:   Street Address      City   State
JOB TITLE:
SUPERVISOR'S NAME:   First Name   Last Name
REASON FOR LEAVING:
HOURLY RATE/SALARY:
MAY WE CONTACT:   Yes   No
REFERENCES

List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).
NAME:   First Name   Last Name
RELATIONSHIP:   Type a label
YEARS KNOW:   Type a label
PHONE:   Area Code   Phone Number

NAME:
RELATIONSHIP:
YEARS KNOW:
PHONE:

NAME:   First Name   Last Name
RELATIONSHIP:   Type a label
YEARS KNOW:   Type a label
PHONE:   Area Code   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 a criminal background check at my cost, proof of identity and legal authority to work in Canada, 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.
Applicant’s Signature

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Date

MonthDayYear
Date
Should be Empty:

Application for Employment

EDUCATIONAL BACKGROUND

PLEASE ANSWER THE FOLLOWING QUESTIONS

EMPLOYMENT BACKGROUND

REFERENCES