PCI Staffing Inc

Application Form

Application for Employment

 Date of this Application:

Personal Information

Last Name:

First Name:

Initials:

Street Address:

City:

Province:

Postal Code:

Telephone No.:

E-mail Address:

Are you legally entitled to work in Canada?

Yes No

 Type of Employment Sought

. 
Check the box for the position (s) you are seeking:

. 
Registered Nurse
LPN or RPN
Health Care Aide or Personal Support Worker
Homemaker
Housekeeping
Companion/Sitter
Other (Please explain):
.....

. 
Type of Employment Sought (check):

. 
Full Time
Casual Part Time
Shift Work
Weekends

. 
Times available for work:

. 
.

Date of availability if hired:

Location applied for:

Select from this drop down menu Calgary North AB Calgary South AB Edmonton North and South AB Lethbridge AB Medicine Hat AB Red Deer AB Burnaby BC Comox Valley (and Courtenay) BC Coquitlam / Maple Ridge BC Cranbrook BC Duncan BC Fraser Valley BC Kelowna BC Nanimo BC North Shore (North Vancouver) BC Penticton BC Prince George BC Surrey / Richmond BC Vancouver BC Vernon BC Victoria BC Lloydminister SK Moose Jaw SK Regina SK Saskatoon SK Brandon MB Neepawa MB Selkirk MB Winipeg North and South MB Barrie / Simcoe County ON Brampton On Brockville ON Burlington / Hamilton N. / Stoney Creeek ON Chatham ON Cornwall ON Elliot Lake ON Etobicoke and West Toronto ON Guelph ON Hamilton ON Kingston ON Kitchner / Waterloo ON London ON Mississauga ON North Bay ON Ottawa Central ON St. Catharines ON Sudbury ON West Toronto ON York Region South ON York Region North ON Montréal Banlieu Quest - Western Suburbs QC Montréal Sud-Quest - South West Montreal QC Québec / Sainte-Foy / PortNeuf QC St-Jean-Sur-Richelieu QC Fredericton NB Miramichi / Bathurst NB Saint John / Moncton NB Halifax NS Charlottetown (Island Wide Service) PEI

 Education, Training and Work Skills

.
Indicate the highest grade or year completed:

.
. Grade 12 Grade 11 Grade 10 Grade 9

. Post Secondary Year 1 Post Secondary Year 2 Post Secondary Year 3 Post Secondary Year 4
.

Other education or training:

Date of this training:

.

Additional applicable work skills:

Work History

.
Beginning with your most recent employer, please provide the following information about each employer.

Employer:

Your position:

 Address:

Supervisor's name:

Telephone No.:

Employed from - to:

Job duties:

Rate of pay:

May we contact employer?

Yes

No

Employer:

Your position:

 Address:

Supervisor's name:

Telephone No.:

Employed from - to:

Job duties:

Rate of pay:

May we contact employer?

Yes

No

Employer:

Your position:

 Address:

Supervisor's name:

Telephone No.:

Employed from - to:

Job duties:

Rate of pay:

May we contact employer?

Yes

No

.Criminal Record

.
Have you ever been convicted of a criminal offence for which a pardon has not been granted?

.
.

Yes

No

.Personal References

.
Give the names, addresses and phone numbers of two persons whom we can approach for a reference.
Do not include the names of relatives.

Name:

Occupation:

Address:

Telephone No.:

Name:

Occupation:

Address:

Telephone No.:

Your knowledge of PCI Staffing Inc as an Employer

.
How did you find out about employment opportunities with PCI Staffing Inc?

.
.

Certification

I certify that the foregoing statements are full, complete and true.     I agree that if there is any failure to disclose or any misrepresentation of any material required to be stated in the foregoing statements,        PCI Staffing Inc may terminate my contract of employment and all      benefits arising from it shall be void from their commencement.          

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