1.
Name :
2.
Phone number :
3.
Street Address :
4.
City :
5.
Province :
6.
Postal Code :
7.
Have you taken a First Aid or CPR course? If so, when?
8.
Do you have valid driver's license?
9.
Why are you interested in working with elderly?
10.
Are you allergic to pets?
11.
Have you ever been convicted of a criminal offence?
12.
Educational background?
13.
Language(s) Spoken
14.
Other training and work experience
15.
Interests
16.
Ability to work
Monday to Friday :
Part Time
Full Time
Shifts
Saturday :
Part Time
Full Time
Shifts
Sunday :
Part Time
Full Time
Shifts
17.
Would you be willing to assume a full time live-in position?
Yes
No
18.
Do you have a Canadian Social Insurance Number?
19.
Are you between 18 and 64 years of age?
20.
Are you legally eligible to work in Canada?
21.
Are you on a work permit?
22.
Are you bondable?
23.
Have you ever been bonded?
24.
Do you give your consent for a criminal record check for bonding/insurance purposes?
25.
Employment History:
Employer1:
Name of the Employer :
Address :
Telephone Number :
Dates Employed :
Brief Summary of Position :
Reason for Leaving :
Contact Name and Position :
Employer2:
Name of the Employer :
Address :
Telephone Number :
Dates Employed :
Brief Summary of Position :
Reason for Leaving :
Contact Name and Position :
Employer3:
Name of the Employer :
Address :
Telephone Number :
Dates Employed :
Brief Summary of Position :
Reason for Leaving :
Contact Name and Position :
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