"Our Caring You'll Remember"

Employment Application

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Please enter your email address:
Date available to start:
Position applied for:
Accommodations are available on request for candidates taking part in all aspects of the selection process.
How did you hear about this position?
Newspaper Job Bank Friend Other    If other, please indicate:
Referred by current NNR employee? Yes No
If yes, please complete information on final page.
 
Please fill out all fields for application to be valid.
 

PERSONAL DATA

Last Name: Given Name(s):
Address:
Home Telephone: Bus. Telephone:
Do you have a Driver's License? Yes No
Reliable transportation? Yes No

EDUCATION

University
Name of Course:
Major Subject:
Degree Awarded:
Community College
Name of Program:
Length of Program:
Diploma/Certificate Received:

Other professional licenses, certificates, degrees you have:
Describe any special skills, experience or training related to the position applied for:

Are you employed elsewhere? Yes No    If yes: Full-time Part-time
Will NNR be Your PRIORITY? Yes No

EMPLOYMENT RECORD (beginning with most recent)

Name:
Address:
Supervisor's Name:
Tel. #:
Employed from: to
Job Title:
Function/responsibilities:
Reason for leaving:

Name:
Address:
Supervisor's Name:
Tel. #:
Employed from: to
Job Title:
Function/responsibilities:
Reason for leaving:

Name:
Address:
Supervisor's Name:
Tel. #:
Employed from: to
Job Title:
Function/responsibilities:
Reason for leaving:

Are you legally eligible to work in Canada? Yes No
Are you willing to work shift work? Yes No
Do you have reliable transportation? Yes No
Do you have a valid driver's license? Yes No
Do you have valid automobile insurance? Yes No
Have you ever been convicted of a criminal offence for which a pardon has not been granted? Yes No
Are you bondable? Yes No
Notification in case of emergency
Next of Kin:
Phone number:

REFERENCES (2 professional, 1 personal - no relatives please) Professional = supervisor or peer of equal designation

Name:
Address:
Tel:
Occupation:
Years known:
Professional Reference Personal Reference

Name:
Address:
Tel:
Occupation:
Years known:
Professional Reference Personal Reference

Name:
Address:
Tel:
Occupation:
Years known:
Professional Reference Personal Reference

May we approach your employers for references?
Present/last employer: Yes No
Former employers: Yes No
I hereby declare the information given is true and complete to the best of my knowledge and I hereby give permission for Nightingale Nursing Registry Ltd. and/or its designated representative to contact the above noted references. I understand that false statements may disqualify me from employment or cause my dismissal.

I declare that by checking this box, it acts as my signature for this digital copy.

Date:

AVAILABILITY/WORK AREA

APPLICANT:      PSW HMK
Hours: Monday to Sunday, irregular hours
Shift Type:
Full Time
Days 07:00 - 17:00
06:00 - 14:00
  Evenings 14:00 - 22:00
15:00 - 23:00
  Overnights 20:00 - 07:00
Shift Type:
Part Time
Days 06:00 - 12:00
09:00 - 15:00
  Evenings 14:00 - 20:00
16:00 - 22:00
Shift Type:
Casual
Days
  Evenings
  Overnights

Nightingale asks that employees be available to work two weekends out of four as the need arises.
I am able... I am not able... to accomodate this schedule.
I am willing to drive in rural areas: Yes No

By checking this box I understand that my circumstances could change and I agree to advise Nightingale by phone in order to keep the availability/work area records up-to-date.
Date:

NNR Employee Referral Information

NNR Employee (referring):
Tel. Number:

Interviewer to contact NNR employee to verify information and forward information to Alison Garbutt, Director of Accounting and Payroll.

Verification:
NNR Employee name Contacted on
Referred (name) to NNR date:

I declare that by checking this box, it acts as my signature for this digital copy.

RELEASE OF INFORMATION FORM

I am applying for employment with Nightingale Nursing Registry LTD.

I hereby authorize (check either or both boxes)...
My previous employer(s)
Present employer
... to release to Nightingale Nursing Registry LTD. any information relating to my previous or present employment.

By checking this box, I give my express permission to Nightingale Nursing to verify my resume and application, and education and experience.

Date: