Application for Employment Application for Employment Name(Required) First Middle Last Address Street Address City State / Province / Region ZIP / Postal Code Telephone NumberCell Phone NumberEmail Address(Required) Position(s) applied forPosition(s) applied for Chief Nursing Officer Director of Nursing Nurse Manager or Nurse Supervisor Advanced Practical Nurse or Clinical Nurse Specialist Nurse Practitioner Clinical Nurse Charge Nurse Staff or Bedside Nurse Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Certified Nursing Assistance (CNA) Other Date available MM slash DD slash YYYY Type of employment desired Full-Time Part-Time Casual Please Specify Days and HoursRate of Pay Expected $ (Per Hour)Are you legally eligible for employment in this country? Yes No Are you available to work overtime if required? Yes No Have you applied with this company before? Yes No If yes, when and at what location?Do you have any friends or family employed at this location? Yes No Have you been convicted of a crime in the last seven (7) years? Yes No If yes, please explain (*CONVICTION WILL NOT NECESSARILY BE A DISQUALIFICATION FOR EMPLOYMENT. )If considered for hiring, will you agree to provide a criminal background check? Yes No If considered for hiring, will you agree to provide a driver’s abstract? Yes No N.A. EDUCATIONAL BACKGROUNDList previous three (3) educational institutions attended, beginning with the most recent.What Nursing or relevant designations, licenses or registrations if any, do you possess?TypeDate of Most Recent Registration MM slash DD slash YYYY Valid in State/Province ? Yes No Do you have the following:CPR Yes No Last Certified MM slash DD slash YYYY First Aid Yes No Last Certified MM slash DD slash YYYY WHMIS Yes No Last Certified MM slash DD slash YYYY PLEASE ANSWER THE FOLLOWING QUESTIONSWhat 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 patients/seniors with 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 BACKGROUNDPlease provide the following information beginning with the most recent employer. Employer: Address Street Address City State / Province / Region ZIP / Postal Code Phone NumberDates Employed MM slash DD slash YYYY Starting and Ending Salary: Summarize the type of work performed and job responsibilities:Immediate Supervisor and Title and Phone Number: MM slash DD slash YYYY Reason for Leaving:May we contact for reference: REFERENCESList the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).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 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.(Required) 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 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.
