APPLICATION FOR EMPLOYMENTPlease complete application in its entirety. PERSONAL INFORMATION Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### Email * Are you legally entitled to work in Canada? * Yes No Are you aware of any health or physical conditions that could affect performance on the job? * Yes No Please elaborate POSITION INFORMATION Position(s) applied for Date Available * MM DD YYYY Willing to Work * Casual Part-Time Full-Time Days Evenings Nights Weekends CRNM, CLPN, or other Professional Registration # Expiry Date MM DD YYYY EDUCATION High School Location Course, Certificate, Diploma, Degree Post Secondary Location Course, Certificate, Diploma, Degree COMPETENCIES Describe any of your work related skills, experience or training that relate to the position being applied for. EMPLOYMENT HISTORY List your last three (3) employers beginning with the present or most recent. #1 Employer Name Dates employed MM DD YYYY Supervisor Address Phone Number (###) ### #### Email Position and Duties Reason for Leaving #2 Employer Name Dates employed MM DD YYYY Supervisor Address Phone Number (###) ### #### Email Position and Duties Reason for Leaving #3 Employer Name Dates employed MM DD YYYY Supervisor Address Phone Number (###) ### #### Email Position and Duties Reason for Leaving LANGUAGES Please indicate all languages including English that you speak, read or write. Language * Speak * Beginner Intermediate Advanced Read * Beginner Intermediate Advanced Write * Beginner Intermediate Advanced Language 2 Speak Beginner Intermediate Advanced Read Beginner Intermediate Advanced Write Beginner Intermediate Advanced Language 3 Speak Beginner Intermediate Advanced Read Beginner Intermediate Advanced Write Beginner Intermediate Advanced Language 4 Speak Beginner Intermediate Advanced Read Beginner Intermediate Advanced Write Beginner Intermediate Advanced APPLICANT’S CERTIFICATION AND AGREEMENT Have you ever been employed by Tabor Home Inc.? * Yes No Or Southern Health-Santé Sud (former RHA Central MB Inc.)? * Yes No If yes, please list the facility/program and dates. Facility/Program Date Employed Start Date MM DD YYYY End Date MM DD YYYY I declare the foregoing information to be true and complete to the best of my knowledge and understand that any misrepresentation or material omission is grounds for refusal to employ me or, if I am employed, for dismissal with cause. If employed I agree to abide by the policies, procedures and working conditions established and/or amended from time to time by Tabor Home Inc. I hereby authorize Tabor Home Inc. to conduct a personal investigation in connection with my application for employment including a Criminal Record Check, Vulnerable Sector Search, Child Abuse Registry Check and Adult Abuse Registry Check. All costs associated with these checks will be my responsibility. I hereby authorize my current or former employers to release information regarding my record of employment, performance on the job, reason for leaving (if applicable) and other pertinent information. Signature of Applicant * Type your full name Date * MM DD YYYY Employment is contingent on an acceptable Criminal Record Check, Child Abuse Registry Check, and Adult Abuse Registry Check acquired by the applicant. Note: all applications for employment will be kept on file for a six-month time period. We thank you for your application. Only those individuals selected for an interview will be contacted. Thank you!
