(Please complete one application for each employment opportunity)
Position Applied for: Please list any add'l applications in past 3 months: Employment Preference: Last Name: First Name: Previous name used in Education/ Employment (if applicable): Street Address: Postal Code: City/Province: Telephone: Are you presently employed with CMHA? Are you legally authorized to work in Canada? Have you worked previously for CMHA? (if Yes, give dates) Are you related to anyone presently working for CMHA? if Yes, to whom? How did you learn about this position? if Other, please specify? Education (Please also attach resume) NAME & LOCATION OF SCHOOL YEARS ATTENDED DATE GRADUATED COMPLETED DEGREE, DIPLOMA or CERTIFICATE (e.g. BA, DSW) HIGH SCHOOL POST SECONDARY Professional Registration or Affiliation CPR Certification (if Applicable) First Aid Certification (if Applicable) Active: Active: Active: Expiry Date (YYYY- MM-DD) Alt Tel#: Expiry Date (YYYY- MM-DD) Expiry Date (YYYY- MM-DD) No Yes No Yes No Yes Email: Print Form (Select One) Print Form Submit by Email Employment History (Start with your most recent employment) Organization Name & Location: Position: Other: FROM: Dates of Employment (YYYY-MM-DD): Hours per Week: Supervisor Name & Title: Reasons for Leaving: Organization Name & Location: Position: Other: Hours per Week: Supervisor Name & Title: Reasons for Leaving: Organization Name & Location: Position: Other: Hours per Week: Supervisor Name & Title: Reasons for Leaving: Organization Name & Location: Position: Other: Employment Status: Hours per Week: Supervisor Name & Title: Reasons for Leaving: TO: FROM: Dates of Employment (YYYY-MM-DD): TO: FROM: Dates of Employment (YYYY-MM-DD): TO: FROM: Dates of Employment (YYYY-MM-DD): Please Indicate your years of experience in a human services environment? Please Indicate your years of experience working with individuals with a mental health concern? Please Indicate your years of experience in supervising staff? TO: Check if Current Employer Employment Status: Hours per Week: Employment Status: Hours per Week: Employment Status: Updated: January 2011 (Select One) (Select One) (Select One) (Select One) Employment References NAME TITLE/COMPANY RELATIONSHIP PHONE # EMAIL Have you ever been convicted of a criminal offence for which a pardon has not been granted? NAME If Yes, Please Explain: I authorize CMHA to obtain references from past and present employers (as indicated below) and I release CMHA from liability or damages incurred as a result of any inquiry made and the furnishing of this information. Your Present Employer Your Former Employers I certify that the statements made by myself in this application are true, accurate and complete. I understand and agree that a false statement made either in this application or during the course of my candidacy for employment with CMHA may disqualify me from employment or result in dismissal.
I also understand that any personal information that I have disclosed during the course of my candidacy or in my application for employment may be shared with members of the Hiring Committee, the CMHA HR department or appropriate members of the CMHA management team at any time during the course of my candidacy or thereafter, should I become employed by CMHA or not, for any reasonable employment purposes. Date: Successful applicants will be required to provide proof of education credentials upon hire and complete a criminal record check
We thank all applicants but only those under consideration will be contacted. By completing this application form, I agree to the terms as indicated above:. No Yes No Yes No Yes No Yes Updated: January 2011 PLEASE NOTE: This form must be completed in Adobe Reader or Professional in order to function properly Submit by Email