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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