APPLICATION FOR EMPLOYMENT

Only applications completed in full will be reviewed, please ensure you print clearly.
PERSONAL DATA:
Name: (First and last) ____________________________________________________________________________

Full Address: (#, Street, Apt., City, Province, Postal Code) _______________________________________________

______________________________________________________________________________________________
Phone Number: (Daytime) ____________________________ (Evening) _________________________________

Are you legally eligible to work in Canada? ο Yes ο No

Have you ever been convicted of a criminal offence for which you have not received a pardon? ο Yes ο No
Have you been employed by Leisureworld before? Yes No ο ο
If yes, where ____________________________________________________________________________________
Are you the spouse, parent or child of a current Leisureworld employee? ο Yes ο No

If yes, Who: __________________________ Position: _________________ Location: _______________________

HOW DID YOU HEAR ABOUT THIS OPPORTUNITY?

ο Monster ο Newspaper ο Leisureworld Website ο Job Fair ο HRDC ο Other ____________ ο

Employee Referral (List Name and Home of employee) __________________________

POSITION APPLYING FOR:

ο Registered Nurse (RN) ο Registered Practical Nurse (RPN) ο Personal Support Worker (PSW)
ο Other (please specify) __________________________________________________________________________

AVAILABILITY:

ο Days ο Evenings ο Nights ο Weekends ο Full Time ο Part Time

Date available to begin work? ________________________________________________________________

LOCATION INTERESTED IN:

ο Barrie ο Brantford ο Etobicoke ο Gravenhurst ο North Bay ο Richmond Hill ο Toronto GTA
ο Brampton ο Creemore ο Elmira ο North York ο Orillia ο Scarborough οVaughan
ο Oxford ο Streetsville ο Mississauga ο Altamont

1/16/09
Please complete this section if you are NOT attaching a resume.
EDUCATION: Documents of proof will be required upon offer of employment
Academic Institution Program Studied Diploma/Degree/License/Certificate Obtained
College
University
Other

EMPLOYMENT HISTORY: Begin with the most recent employer

Employment Date (mm/dd/yy): From: To: Status: ο Full Time ο Part Time
Employer: Position:

Address: Telephone:

Name and Title

Reason for Leaving:
of Supervisor:

Describe work and responsibilities:

Employment Date (mm/dd/yy): From: To: Status: ο Full Time ο Part Time
Employer: Position:

Address: Telephone:

Name and Title

Reason for Leaving:
of Supervisor:

Describe work and responsibilities:

Employment Date (mm/dd/yy): From: To: Status: ο Full Time ο Part Time
Employer: Position:

Address: Telephone:

Name and Title

Reason for Leaving:
of Supervisor:

Describe work and responsibilities:

I hereby declare that the foregoing information is true and complete. I understand that a false statement may disqualify me from employment,
or result in my termination for just cause. I understand further that any offer of employment made is subject to two (2) satisfactory references
and a satisfactory criminal reference check. Any reference information obtained will be kept confidential and not be released. I acknowledge
and agree that should the any reference check be deemed unsatisfactory, any offer of employment which may have been extended will be
withdrawn.

I acknowledge that an initial and/or annual medication examination may be required as a condition of my continued employment.

Applicant’s Signature: Date: ____________________________

1/16/09