Careers Form

Name *(Last, First, Middle)

Date

Address *

City

State/Province

ZIP/Postal Code

Telephone # *

Cell Phone #

E-Mail address *

Referred to us by

Position(s) applied for

Caregiver

Nursing

Other

Date Available

Type of employment desired

Full-Time

Part-Time

Casual

Specify Days and Hours

If currently employed, may we contact your employer?

Yes

No

Rate of Pay Expected per hour

Is there a specific reason you are applying for employment at this company?

Yes

No

Please briefly outline the reason

Are you legally eligible for employment in this country?

Yes

No

Are you available to work overtime if required?

Yes

No

Have you applied with this company before?

Yes

No

Have you been employed at this company before?

Yes

No

When?

What location?

Do you have any friends or family employed at this location?

Yes

No

Have you been convicted of a crime in the last seven (7) years?

Yes

No

Please explain CONVICTION WILL NOT NECESSARILY BE A DISQUALIFICATION FOR EMPLOYMENT.

If considered for hiring, will you agree to provide a criminal background check?

Yes

No

If considered for hiring, will you agree to provide a drivers abstract?

Yes

No

N.A

EDUCATIONAL BACKGROUND

List previous three (3) educational institutions attended, beginning with the most recent.

Name of School

City, State/Province

Graduated?

Yes

No

Degree(s)/Diploma(s) Earned

Name of School

City, State/Province

Graduated?

Yes

No

Degree(s)/Diploma(s) Earned

Name of School

City, State/Province

Graduated?

Yes

No

Degree(s)/Diploma(s) Earned

What Nursing or relevant designations, licenses or registrations if any, do you possess?

Type

Date of Most Recent Registration

Valid in State?
Yes No
Yes No

Do you have the following?

CPR
First Aid
WHMIS

Last Certified

PLEASE ANSWER THE FOLLOWING QUESTIONS

What do you think is the most difficult part of nursing or customer service work?

What was the best job you ever had and why?

What was your least favourite job and what did you dislike about it?

Think of the BEST supervisor you have ever had, what characteristics made that person a good manager?

Think of the WORST supervisor you have ever had, what characteristics made that person a poor manager?

How will you be able to contribute to providing seniors with high quality care?

Imagine you have been on your feet and working hard all day. A customer that you have been dealing with is rude and impatient, what do you do?

EMPLOYMENT BACKGROUND

Provide the following information beginning with the most recent employer.

Name of employer

Telephone

Employment Dates
From

To

Hourly Rate/Salary Starting

Hourly Rate/Salary Final

Address

Job Title

Immediate Supervisor

Phone Number

Reason for leaving

May we contact for reference?

Yes

No

Later

Summarize the type of work performed and job responsibilities

Name of employer

Telephone

Employment Dates
From

To

Hourly Rate/Salary Starting

Hourly Rate/Salary Final

Address

Job Title

Immediate Supervisor

Phone Number

Reason for leaving

May we contact for reference?

Yes

No

Later

Summarize the type of work performed and job responsibilities

Name of employer

Telephone

Employment Dates
From

To

Hourly Rate/Salary Starting

Hourly Rate/Salary Final

Address

Job Title

Immediate Supervisor

Phone Number

Reason for leaving

May we contact for reference?

Yes

No

Later

Summarize the type of work performed and job responsibilities

REFERENCES

List the name, relationship, number of years acquainted, and phone number of two references. (NO RELATIVES PLEASE).

Name

Relationship

Years Acquainted

Phone Number

Name

Relationship

Years Acquainted

Phone Number

*I certify that all the information I have provided is true, complete and correct.

The information contained within this application or any cover letter or resume attached is not shared with any third parties. The information is used by the employer only as an aid in the hiring decision making process. The applicant, by signing the application gives the employer, Dove Health Care Services, consent to collect the information contained herein and use for the purpose specified.

I authorize Dove Health Care Services to investigate all statements contained on this application. I understand that any misrepresentation or omission of facts called for is cause for immediate disqualification and/or if employed, immediate dismissal.

I understand that if I am hired, I will be required to provide criminal background check at my cost, proof of identity and legal authority to work in America, proof of certifications or educational qualifications, and a drivers abstract (if applicable).

Furthermore, I understand and agree that if employed, I am free to resign at any time, with or without cause and without prior notice, and Dove Health Care Services reserves the same rights to terminate my employment at any time, with or without prior notice, except as may be required by law. This application does not in any way constitute an agreement or contract for employment.

Name of Applicant *

Date