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MIDDLECHURCH HOME OF WINNIPEG INC

APPLICATION FOR EMPLOYMENT

 

Personal Data

First Name       
Last Name       
Address           
Phone #           

1.    Are you legally entitled to work in Canada?     Yes / No 
2.    Do you have any disabilities or health problems affecting positions applied for?    Yes / No  
       Please Explain 
3.    Are you bondable?    Yes / No  
4.    Have you been found to be at fault during an investigation by the "Persons for Protection in Care Office"?   
       Yes / No 

Employment Data

Position Applying      
Date of Availability      
Shifts/Days of Week Desired  

Educational and Skills

Institution

School     
Grade, Degree, Diploma or
Certificate Completed and Date  
Area of Study    

Community College    
Grade, Degree, Diploma or
Certificate Completed and Date  
Area of Study    

University     
Grade, Degree, Diploma or
Certificate Completed and Date  
Area of Study    

Certifications     
Grade, Degree, Diploma or
Certificate Completed and Date   |
Area of Study    

Please describe other proven skills and abilities you possess.


Employment History
Please list in order beginning with most recent employment.

Employer Name and Address     
Position and Dates (From-To)     
Reason for Leaving                     

Employer Name and Address     
Position and Dates (From-To)     
Reason for Leaving                     

Employer Name and Address     
Position and Dates (From-To)     
Reason for Leaving                     

Other

1.    Have you been previously employed at MCH?    Yes / No  
       (If yes, please list position and employment dates.)   
2.    Please list any referrals from an employee of MCH
                             
3.    Please list any languages (other than English) you can speak, read or write. 

APPLICANTS STATEMENT AND AGREEMENT

I herby certify that the foregoing answers are correct to the best of my knowledge.  I understand that any misrepresentation will be considered as just cause for rejection of this application and dismissal from employment.

Signature          Date   

 

Do you have a current Criminal Record Check, Adult Abuse Registry, and Child Abuse Registry not older than 6 months from today’s date? 
No  
        Yes

____________________________________________________________________________________________

For Office Use Only

References Sent                        Date  __________________                    Personnel Office Initial    _______

References Returned                 Date    __________________                    Personnel Office Initial    ______

References Forwarded to Supervisor/Manager           Date  ______________              Personnel Office Initial    _______

File on Hold        _____________________________________________

File Rejected        ____________________________________________

 

 

 

                                                                                                                    Authorization

                                                                                           _________________________________________
                                                                                              Signature of Department Head/Manager/Supervisor