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Job Application Form - GTA West

Employment Application

Personal Information

Name:	First: Middle Initial: Last:
Address:	Street: Apartment: City: Prov.: Postal Code:
Phone:	Home: Cell: Other:
E-Mail:	Email Address:
	Are you legally entitled to work in Canada? Yes No What languages do you speak?

Education

	Course/Degree	School's Name	Degree Rec'd: Yes/No	Year Degree Rec'd
High School
College/University
Other/Specify

Please check any of the following certifications you currently possess.

	Expiry Date (if applicable)
CPR
First Aid
Food Safety Certificate
Other

Restrictions

Work
Limitations:

Do you have a disability which will affect you ability to perform any of the functions of the Personal Support Worker Position?
Yes No

If the above answer is "yes", then:

What functions can you not perform and what accommodations need to be made which would allow you to do the work more adequately?

Availability for Work

Client Types and Work Duties

Experience:

How would you rate yourself on your experience with the following aspects of caregiving?
1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience:

Bathing/Showering	Companionship
Grooming	Laundry
Medication Reminding	Meal Preparation
Dressing	Shopping
Bowel Care	Escorting & Transporting Clients
Bladder Care	Palliative Care
Feeding	Housekeeping
Ambulation	Cooking

Assignment
Location:

Are you restricted in the geographical location you are willing/able to work? Yes No
Explain:

Transportation

Type Available

Personal Vehicle Public Transportation Other:

Drivers:

	Y	N
If requested are you able to provide us with a driver's abstract?
Do you have any convictions under the Highway Traffic Act?

Criminal Background Check

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

Yes No

Voluntary Positions

Please describe any volunteer positions you have experience with in non-profit agencies, places of worship, hospitals or other organizations, if any.

Organization	Type of Work	From	To

Employment History & Reference Details

(Starting with the most recent job)

Employment
Reference #1

Name: Phone#
Address:
Last Position Held:
Length of Employment:
Reason for Leaving:

Employment
Reference #2

Name: Phone#
Address:
Last Position Held:
Length of Employment:
Reason for Leaving:

Employment
Reference #3

Name: Phone#
Address:
Last Position Held:
Length of Employment:
Reason for Leaving:

References

Professional
Reference:

Name:
Address:
Telephone No.: Email Address:
Reporting Relationship:

Character
Reference:

Name:
Address:
Telephone No.: Email Address:
Nature of Relationship (client, co-worker, teacher, etc.):

AUTHORIZATION TO RELEASE INFORMATION

Living Assistance Services is an equal employment opportunity employer dedicated to a policy of non-discimination in employment upon any basis, including race, color, creed, religion, age, sex, national origin, ancestry, sexual orientation, marital status, military status, or the presence of any non-job-related medical condition of handicap.

Please keep in mind that the questions contained in this application are not intended to be discriminatory based on any non-job-related information.

We want you to know that we will be checking your references as part of our hiring process. This may include contacting your former employers, as well as friends, acquantances and business associates. We may ask a series of questions about your personal background, work experience, character, education or personality.

AFTER READING THIS POLICY, PLEASE INDICATE YOUR AGREEMENT BY SIGNING IT IN THE SPACE PROVIDED:

I have read and fully understand the foregoing and voluntarily consent to allow Living Assistance Services to check my references by contacting any person whom they deem to be an appropriate reference. Questions may be asked about my personal background, work experience, personality, personal habits and education.

I, , (please type your name here) hereby authorize my prior employer(s):

1.
2.
3.

To release any and all information relating to my employment with Living Assistance Services.

I further release and hold harmless the above mentioned employers and Living Assistance Services from any and all liability that may potentially result from the release and/or use of such information.

I understand that any information released by my prior employer will be held in strictest confidence, that it will be viewed only by those involved in the hiring decision, and that neither I nor anyone else not so involved will have the right to see the information.

Applicant's Signature