APPLICATION FOR EMPLOYMENT

EMPLOYMENT APPLICATION FORM

The Human Rights Code prohibit discrimination in employment because of race, national or ethnic origin, religion, age, sex, marital status, family status, disability or conviction for an offence for which a pardon has been granted.

SECTION A: PERSONAL Date______

(mm) (dd) (yy)

Name ______

Last First Middle Initial

Present Address ______

Postal Code ______Telephone ( )______

Area Code

Job (s) applied for ______Rate of pay expected $ ______per ______

How did you learn of this opening?______

Do you want to work Full-time or Part-time. Specify days and hours if part-time

______

Are you willing to work any day or shift if required? ______

Have you worked for us before? ______If yes, when? ______

Are you legally entitled to work in Canada? ______

Are you over the age of 18 years and under the age of 65? ٱ No ٱ Yes

Do you have a relative presently working at Belmont House? ٱ No ٱ Yes

If yes, state nature of relationship (ie. spouse, son, daughter, etc.): ______

If hired, on what date will you be available to start work? ______

(mm) (dd) (yy)

Are there any other experiences, skills, or qualifications, which you feel would especially fit you for work with us?

______

______

If hired, do you have a reliable means of transportation to get to work? ______

(Belmont House operates 7 days a week - 24 hours a day)

Are you bondable? (Answer question only if information is relevant to position applied for)  Yes  No

Have you ever been convicted of a criminal offence for which a pardon has not been granted?  Yes  No

Have you enclosed a resume? ٱ No ٱ Yes If yes, do not complete Sections B and C on the next page.

SECTION B: EDUCATIONAL BACKGROUND

TYPE OF SCHOOL
/ NAME & ADDRESS / FROM / TO / GRADUATED / COURSE OR MAJOR
SECONDARY / Yes No
COLLEGE / Yes No
POST GRADUATE / Yes No
BUSINESS OR TRADE / Yes No
OTHER / Yes No

SECTION C: PRIOR WORK HISTORY (LIST IN ORDER, LAST OR PRESENT EMPLOYER FIRST)

RATE OF PAY
DATES
FROM/TO / NAME, ADDRESS & PHONE NO. OF EMPLOYER / Start / Finish / SUPERVISOR’S NAME & TITLE / REASON FOR LEAVING
RATE OF PAY
DATES
FROM/TO / NAME, ADDRESS & PHONE NO. OF EMPLOYER / Start / Finish / SUPERVISOR’S NAME & TITLE / REASON FOR LEAVING
RATE OF PAY
DATES
FROM/TO / NAME, ADDRESS & PHONE NO. OF EMPLOYER / Start / Finish / SUPERVISOR’S NAME & TITLE / REASON FOR LEAVING

May we contact the employers listed above? ____ If not, indicate below which one(s) you do not wish us to contact.PERSONAL REFERENCES

Give the names of at least 2 persons who can supply information pertinent to your job performance (excluding former employees or relatives).

NAME AND OCCUPATION / ADDRESS / PHONE NUMBER

Thank you for completing this application form and for your interest in employment with us. We would like to assure you that your opportunity for employment with this company will be based only on your merit and on no other consideration.

CONSENT FOR VERIFICATION:

I authorize investigation of all statements herein which may include a police check and release Belmont House and all others from liability in connection with same. I also understand that untrue, misleading or omitted information herein may result in dismissal, regardless of the time of discovery by the Home. All statements become part of any future employee personnel files.

Date ______Signature of Applicant ______

(mm) (dd) (yy)

======

APPLICANT - COMPLETE THIS SECTION ONLY AFTER YOU ARE HIRED.

Date of Birth ______Social Insurance No. ______

(mm) (dd) (yy)

N.B. These cards must be presented to your employer for verification.

Verified by ______Name & Title ______

Signature

What name would you like on your employee name tag? ______

(Please specify Mr./Mrs./Miss/Ms)

Person to be notified in case of accident or emergency
Name ______Phone Number: (Home) ______
(Office) ______
Address: ______
Relationship: ______

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