NAME OF CANDIDATE: ____________________________________ File: W___________________

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ADDITIONAL FORM FOR LIVE-IN CAREGIVER

1. Please provide your phone numbers where you can be contacted during the day; also include your email and current mailing address. Area code Number Email Address

Current Mailing Address

Provide the name, address, and telephone number of any employment agency or recruitment agency, or any other third party, involved in arranging your job offer as a live-in Caregiver or otherwise involved in facilitating your application for a work permit as a live-in caregiver or your placement as a live-in caregiver. Name of organization/person/ agency involved outside Canada Tel Number Address Valid POEA license? (circle one) Yes No

Legal name of organization/person(s) / agency involved in Canada

Tel Number

Address

Province of business license

Education and training Information:

2. On what basis are you submitting your application? Caregiver course Employment experience Details of your education secondary and post-secondary: Dates From
DD / / MM / / YY DD / /

Educational background (nursing degree, etc.)

3.

Name, address and telephone number of school To

MM / / YY

Type of degree/ certificate/diploma issued

Number of credits/units obtained

* Use additional sheets if necessary 4. Language Ability and Caregiver Skills/Knowledge: I have an appointment to take the S.P.E.A.K. Test on ____________________(date) I am providing alternate evidence of language ability and caregiver skills/knowledge. I understand that my application will be assessed on the basis of the documentation provided and that the onus is on me to establish that I meet the requirements of paragraphs 112(d) and 200(3)(a)of the IRPR.

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5. Please provide the name and address of the school where you attended caregiver training. Name of School Address

6.

What is the exact duration of your caregiver training? From

DD MM YYYY DD

To
MM YYYY

/ 7.

What time and days of the week did you attend your classes? Time Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday From
AM / PM AM / PM AM / PM AM / PM AM / PM AM / PM AM / PM

To
AM / PM AM / PM AM / PM AM / PM AM / PM AM / PM AM / PM

You must provide complete, truthful and accurate information. The information provided may be verified. Providing incomplete, false or misleading information will likely result in a refusal of your application. 8. Did you do any on-the-job training or practicum? If yes, please indicate the exact duration, time and days of the week of your on-the-job training or practicum. Yes (fill out table below) No From
DD MM YY

To /
DD YY MM

OJT Institution / Days of the Week / Time OJT Started and Ended (EXAMPLE: Rizal Hospital, Mon-Fri, 8am 5pm) /

/ /

/ / /

/ / / / * Use additional sheets if necessary 9. If you have a degree in Nursing, are you licensed? Yes PRC # No

*Please attach a copy of your nursing degree and license

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10. Employment details for the last 10 years, including self-employment: Dates From
DD / MM / YY /

To
DD MM / YY

Name, address and telephone number of employer

Your position

Monthly salary

* Use additional sheets if necessary

11. Travel Information:

Do you have any previous overseas travels in the last ten years, and/or have you spent more than 6 months in any th country other than the Philippines since your 18 birthday? Yes (fill out table below) No Duration Country
DD

From
MM YYYY DD

To
MM YYYY

/ / / * Use additional sheets if necessary

/ / /

/ / /

/ / /

*Important: You must provide a police certificate from every country where you have resided for 6 months or th more since your 18 birthday, including the Philippines. For the Philippines, you must provide a recent NBI clearance with dry seal and thumbprint, issued within the last 3 months.
You must provide complete, truthful and accurate information. The information provided may be verified. Providing incomplete, false or misleading information will likely result in a refusal of your application.

Personal Information:
12. What is your current marital status? Single Annulled Married Widowed Legally Separated In a common-law relationship

13.

Please provide details about your family members: Name Relationship Date of birth Spouse/ Common-law partner Son/Daughter
DD MM YYYY

Place of residence (complete address)

Occupation

/ /

/ /

Son/Daughter

Son/Daughter

Son/Daughter

Father

Mother

Brother/Sister

Brother/Sister

Brother/Sister

Brother/Sister * Use additional sheets if necessary

14. Please list any of your relatives living in other countries (i.e. not in the Philippines): Name Country of residence

Exact relationship to you

15. Did you use an agency/third party for this application? Yes (fill out table below and submit authorization of representative form, if applicable) Name of Agency Address Contact number

No Agent Fees

16. Are you related to your prospective employer in Canada? Yes Indicate your relationship to him/her: Yes No

17. Have you been in direct contact (e-mail, phone, other) with your prospective employer? 18. Type of care you will provide (check all applicable): Child(ren) Elderly

No

Disabled

19. Number of persons receiving care (indicate number) ____child(ren), ____ elderly person(s), and/or ___ disabled person(s).

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20. Does your prospective employer currently employ a live-in caregiver?

Yes

No

21. Please list all the members of the household where you will be providing care, and their relationship to your prospective employer, and identify which members will require care and whether any have any special needs. Name of household member (and relationship to prospective employer) (Employer) (Spouse) (Child) (Child) Care Required? Age Please describe any Special Needs (eg. Disability, medical condition, other)

Yes / No Yes / No Yes / No Yes / No

(Child) ( ( ( ( ( ) ) ) ) )

Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No

I declare that I have answered all required questions in this questionnaire and in my application fully and truthfully.

_____________________________________ Printed Name and Signature of Applicant

___________________ Date

Please note that failure to complete all required questions will result in delays in the processing of your application.