Riverside Health Care - Application Form

Riverside Health Care Facilities Inc.

Application Form

Please indicate by checking the appropriate box which health centre you prefer

La Verendrye Health Centre Emo Health Centre Rainy River Health Centre Rainycrest Home for the Aged

I. Personal Data

Name

Surname First Middle

eMail Address

Current Address

Phone Numbers

Home

Cell

Other

Are You Legally able to work in Canada?

Yes

Are You 18 years of age or older?

Yes

II. Position Applied For

Please state Position, Title and Department

First Choice

Second Choice

Do You Wish To Work (please indicate appropriate choice(s))

Full-Time Part-Time Casual

If Part-Time or Casual; Specify days and hours preferred (if Applicable)

If your application is accepted, on what date will you be available to work?

Describe why you are interested in this type of employment with our Hospital

III. Education

To determine your qualifications, please provide below information related to your academic and other achievements (including volunteer work), as well as all employment history.

Secondary School

Highest Grade/Level Completed:

Type of Certificate/Diploma received:

Business,Trade or Technical School

Name of Course

License, Certificate or Diploma awarded? Yes No

Community College

Name of Program

Length of Program:

Diploma Received? Yes No

University

Major Subject

Lenght of Course:

Degree Awarded? Yes No

Pass Honours

Other Courses, Workshops, Seminars

Include Other Licenses, Certificates, Degrees

IV. Employment

Note: Please provide a complete history of all past employment (beginning with most recent employment)

Name/Address of Current/Last Employer

Name/Address of Employer

Name/Address of Empoyer

Name/Address of Employer

Describe any of your work related skills, experience or training that relate to the position being applied for which have not been outlined in other sections of this application.

If you are currently employed, please indicate whether or not you wish your current employer contacted at the present time. Yes No

Note: Riverside Health Care will require permission to contact your current employer if an offer of emplyoment is made

Please Read Carefully:

I declare the information given in this application to be true and understand that any misrepresentation of facts by me may be considered sufficient cause for cancellation of the application or, if I have been employed, summary dismissal. If employed by Riverside Health Care, I agree to be governed by all rules and regulations and agree to submit to any conditions of employment ineffect at the time of my employment or subsequent thereto. I agree to submit to a medical examination as a condition of employment. I hereby authorize Riverside Health Care Facilities Inc. to obtain references from any or all of my previous employers in connection with my application for employment.

Date

Signature: (please type in name)