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Application for Employment at Shalom Manor & Shalom Gardens

Position Applied for:

Nursing Dietary Laundry Maintenance Activation Housekeeping
Clerical Other *Please name the position

Personal Information

Name

First:	*What is your first name?
Middle:
Last:	*What is your last name?

Contact Information

Street Address:	*What is your street address?
Town:	*What city do you live in?
Postal Code:	*What is your postal code?
Telephone:	*xxx-xxx-xxxx

Work Status

Have you worked at Shalom Manor before?	Yes No
Do you have any relatives working at Shalom Manor?	Yes No
Are you legally eligible to work in Canada?	Yes No
Is there anything to prevent you from doing the job(s) applied for?	Yes No

Optional Information

Birthday (optional):	*Either blank or mm/dd/yyyy
Church Affiliation (optional):

Educational Background

Formal Education

Select highest year completed in each category
Elementary School:	None	4	5	6	7	8
High School:	None	9	10	11	12	13
	Describe course of study*What was your course of study in high school?

College/University:	None	1	2	3	4
	Describe course of study*What was your course of study in college?

Graduate/Professional:	None	1	2	3	4
	Describe course of study*What was your post-graduate course of study?

Specialized Training

Describe any specialized training, apprenticeship skills, courses and extra-curricular activities

Certificates/Licenses/Registrations

Professional Body:
Identification #:

Language Skills

	English	Dutch	Other: What language?Speak? Understand? Read/Write?
Read/Write
Speak
Understand

Employment History

Enter your most recent employer first, then the previous employer, ...

First Employer

Employer	*Where did you work?
Position	*What position did you hold?
Address	*What is the company's address?
Telephone	*xxx-xxx-xxxx
Employed	from to *mm/dd/yyyy
Supervisor	*Who was your supervisor?
Job Title	*What was your title?
Duties Performed & Responsibilities:	*Describe your duties
Last Hourly Rate	*$xx.xx
Reason for Leaving	*Why did you leave?
May we contact this employer?	Yes No

Second Employer

Employer	*Where did you work?
Position	*What position did you hold?
Address	*What is the company's address?
Telephone	*xxx-xxx-xxxx
Employed	from to *mm/dd/yyyy
Supervisor	*Who was your supervisor?
Job Title	*What was your title?
Duties Performed & Responsibilities:	*Describe your duties.
Last Hourly Rate	*$xx.xx
Reason for Leaving	*Why did you leave?
May we contact this employer?	Yes No

Third Employer

Employer	*Where did you work?
Position	*What position did you hold?
Address	*What is the company's address?
Telephone	*xxx-xxx-xxxx
Employed	from to *mm/dd/yyyy
Supervisor	*Who was your supervisor?
Job Title	*What was your title?
Duties Performed & Responsibilities:	*Describe your duties.
Last Hourly Rate	*$xx.xx
Reason for Leaving	*Why did you leave?
May we contact this employer?	Yes No

Fourth Employer

Employer	*Where did you work?
Position	*What position did you hold?
Address	*What is the company's address?
Telephone	*xxx-xxx-xxxx
Employed	from to *mm/dd/yyyy
Supervisor	*Who was your supervisor?
Job Title	*What was your title?
Duties Performed & Responsibilities:	*Describe your duties.
Last Hourly Rate	*$xx.xx
Reason for Leaving	*Why did you leave?
May we contact this employer?	Yes No

Personal References:

If you have no prior work history. give the names of at least three persons who can supply personal information (excluding relatives)

First Person

Name	*What is his/her name?
Occupation	*What is his/her occupation?
Address	*Where does he/she live?
Telephone	*xxx-xxx-xxxx

Second Person

Name	*What is his/her name?
Occupation	*What is his/her occupation?
Address	*Where does he/she live?
Telephone	*xxx-xxx-xxxx

Third Person

Name	*What is his/her name?
Occupation	*What is his/her occupation?
Address	*Where does he/she live?
Telephone	*xxx-xxx-xxxx

Occasionally an application form makes it difficult for an individual to adequately summarize their complete background. To assist us in finding the proper position for you in our organization, use the space below to summarize any additional information necessary to describe your full qualifications including any volunteer activities.

Will you provide a criminal reference check at your expense, if so requested? Yes No

Certifications

If employed, I agree to abide by and respect all personnel policies, resident rights, health and safety regulations of the Employer, including the taking of any vaccinations/immunizations required. I hereby certify that the facts set forth in the above employment application are true and complete. I understand that if employed, falsified statements on this application shall be considered sufficient cause for dismissal.