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PERSONAL INFORMATION
Name:
Date:
Home Address:
City, Province, Postal Code:
Home Phone:
Business Phone:
Email:
Are you between the ages of 18 to 65?	Yes No
Have you been employed by this Hospital before?	Yes No
If so, when?
Are you legally entitled to work in Canada?	Yes No
Have you ever been convicted of a criminal offence for which you have not been pardoned?	Yes No

POSITION APPLYING FOR
Position:	Full Time Part Time Casual Student
If applicable, are you available to work all shifts?	Yes No
Date Available:

NURSING APPLICANTS ONLY
Clinical Area Preferred #1:
Clinical Area Preferred #2:
Ontario Certificate of Registration No.:
Date of Issue:
Registration Class:	General Extended Temporary
Level of C.P.R. Certification	Heart Saver B.C.L.S. A.C.L.S.
Date of Expiry C.P.R. Certification:
Date of Last Hospital Employment as R.N. or R.P.N.
Clinical Area of Greatest Experience:
To determine your qualification for employment, please provide below information related to your academic and other achievements including employment history as well as volunteer work. Additional information may be attached on a separate sheet.

EDUCATION
Level	Name of Program	Degree / Diploma (if applicable)
Secondary		Highest grade completed:
College Technical		Length of program:
School of Nursing		Length of program:
University		Major:
Other

PROFESSIONAL AFFILIATIONS

Name of Association	Registration Date	Registration Number

EMPLOYMENT HISTORY: LIST PRESENT OR MOST RECENT EMPLOYER 1ST

Employer		Duties
Position
Date
Supervisor
Telephone
Pay Rate

Employer		Duties
Position
Date
Supervisor
Telephone
Pay Rate

Employer		Duties
Position
Date
Supervisor
Telephone
Pay Rate