Application for Employment

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

RNRPNAdmin.

How did you hear about PICN?*

If there is a person or persons from PICN that has encouraged you to apply for a position with us?please state their name(s):

If hired, can you supply proof that you are legally permitted to work in Canada?*

YesNo

Are you of legal age to work in your province?*

YesNo

Have you ever interviewed with Partners In Community Nursing?*

YesNo

Have you ever worked for Partners In Community Nursing before?*

YesNo

If yes, when and in what position?

Have you been convicted of a criminal offence which is connected to the position you are applying for and for which pardon has not been granted?*

YesNo

If yes, please provide details regarding the nature of the infraction(s) (a criminal conviction will not necessarily be a bar to employment):

Are you fully proficient in english?

ReadWriteSpeak

Language:

Language Proficiency

ReadWriteSpeak

Language:

Language Proficiency

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Employer Name*

Possition*

Dates worked from: Date* to Date*

Reason for leaving:*

Please list any related certifications or licenses you possess:*

Position(s) Desired*

Visting ProgramHome Shift ProgramSchool Program

Availability*

Full TimePart TimeCasual

Desired Starting Wage:*

How many hours are you looking for (per week)?*

Please provide your availability below: (your unavailability to work on any particular day will not necessarilybe a bar to employment)

	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
Morning
Afternoon
Evening
Night

PLEASE READ CAREFULLY BEFORE SIGNING
I agree to provide proof of work eligibility on or before my date of hire. All of the information contained in this application is true and complete. If I have falsified any of this information or if I have omitted information which a reasonable person would consider material to my suitability for the position for which I am applying,
my application will be rejected or if I am hired, my employment will be terminated without notice or pay in lieu of such notice regardless of the time lapse before discovery. Partners In Community Nursing may inquire of such persons, employers, education institutions, investigative consumer reporting agencies, or other entities as it deems appropriate concerning my background and qualifications. I authorize and request all such persons and entities to disclose to Partners In Community Nursing such knowledge of or records concerning me as they may possess and release information and forever discharge all such persons and institutions from any liability of any kind from such disclosure.

My signature is evidence that I have read and agree with the above statement.

Date

Signature

Application for Employment

Knowledge of languages other than english:

Please provide the below information for your most current employment.