Fieldworker Supervisor Application Form
Please complete this application form and send with a resume to by April 1, 2014.
1. Personal InformationFirst Name Middle Name Last Name / Date of Application
Address City Province Postal Code
E-mail Address / Home Telephone No. / Cell or Message No.
Region of the province you are interested in supervising: / Interior Health, Vancouver Coastal and Vancouver Island regions / Northern and Interior regions
Do you have experience working or living in the north?
☐ Yes ☐ No
2. Position Information
Do you self-identify as First Nations, Aboriginal, Inuit, or Metis?
☐Yes ☐No / Are you at least 18 years of age? ☐Yes ☐No / Do you speak a native language?
☐ Yes, which______☐ No
Do you have a valid driver’s license?
☐ Yes, Class ______☐No / Are you willing and able to travel throughout the province via:
☐ Plane ☐ Boat ☐ Car / Do you have use of a vehicle:
☐ Yes ☐ No
Please note, vehicle travel may be required over secondary roads
Do you have use of the following:
☐Internet ☐Cell phone / Can you rate your computer skills?
☐Excellent ☐Good ☐Beginner
Have you completed high school? ☐Yes ☐No / Do you have previous experience supervising staff?
☐Yes ☐No
Do you have previous data collection experience on reserve?
☐Yes ☐No
If yes, please describe your experience using full sentences and proper grammar (in 50 words or less):
3. Employment History
List jobs held in the past 5 years, including present job.
***Complete in full ~ Please do not write “See resume” ****
Name of Employer / Supervisors Name / Contact Telephone No.
Dates Employed
From: ______To: ______/ Reason for leaving? / Position Held
Duties performed (please describe using full sentences and proper grammar) / May we contact them?
☐ Yes ☐ No
Name of Employer / Supervisors Name / Contact Telephone No.
Dates Employed
From: ______To: ______/ Reason for leaving? / Position Held
Duties performed (please describe using full sentences and proper grammar) / May we contact them?
☐ Yes ☐ No
Name of Employer / Supervisors Name / Contact Telephone No.
Dates Employed
From: ______To: ______/ Reason for leaving? / Position Held
Duties performed (please describe using full sentences and proper grammar) / May we contact them?
☐ Yes ☐ No
4. Interest and Skills for Fieldworker Supervisor
In 150 words or less, please describe why you are interested in this position and your skills and knowledge that would make you successful.
5. Professional/ Character References
Name/Title / Company/Location / Telephone / Relationship
☐ / I certify that all answers given herein are true and complete to the best of my knowledge.
☐ / I authorize investigation of all statements contained in this application as may be necessary in arriving at an employment decision.
☐ / In the event of being awarded a contract, I understand that false or misleading information given in my application or interview(s) may result in cancellation of my contract.
☐ / By checking here I authorize the FNHA to submit a criminal records check on my behalf. A criminal record will only preclude a candidate from employment when the nature of the record prevents the candidate from meeting the inherent requirements of the position.
______
Signature of ApplicantDate