AVAILABILITY
How many hours can you work weekly?
When do you want to work your shift?
Type of employment desired:
WORK EXPERIENCE: JOB 1
Cana representative from our company contact your most recent employer?
TRANSPORTATION
Do you currently hold a driver’s licence?
Would you be willing to provide a driving record?
Any driving accidents in the past three years?
How many?
Any driving violations in the past three 3 yrs?
COMMUNICATION
Check the technology devices that you use:
Do you have a data plan on your mobile device?
Will you be willing to fill out a caregiver daily checklist after each visit?
PERSONAL REFERENCE CONTACTS (Excluding family members)
Have they been notified that they are a reference?
EDUCATION INFORMATION
RECOGNITION(S) OR ACCOMPLISHMENT(S)
CRIMINAL BACKGROUND
Have you ever been charged with a criminal offence?
PLEASE READ CAREFULLY
I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the employer permission to contact schools, previous employers (unless otherwise indicated), and references.
This is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, or age. We assure you that your opportunity for this employment position depends solely on your qualifications.
Thank you for completing this application form and for your interest in our company.
