Step 1 of 4 25% Application Date(Required) MM slash DD slash YYYY Your Name(Required) First Last Full AddressYour Email Address(Required) Your Phone(Required)Work Permit Position you are applying for:(Required)CaregiverDo you have a First Aid/CPR certificate?[If YES, please attach copy of certificate to application] Yes No Certification Registration # Expiry Date [MM/YYYY] AVAILABILITYSelect Week Days(Required) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Desired wage amount:(Required)Desired wage(Required) Hourly Weekly Monthly Salary How many hours can you work weekly?(Required) 4-16 16-26 26-40 Can you work nights?(Required) Yes No Can you work weekends?(Required) Yes No Can you work holidays?(Required) Yes No Type of employment desired:(Required) FULL-TIME LIVE OUT PART-TIME LIVE OUT LIVE IN FULL TIME ON CALL What date are you available to start work?(Required) MM slash DD slash YYYY NOTES: WORK EXPERIENCEJob 1Name of Business/Employer:(Required) Job Title/Position:(Required) Employment Dates:(Required)Start [MM/YY] Employment Dates:(Required)End [MM/YY] Phone/Email:(Required) Location:(Required) Person to Contact(Required) Position in Company(Required) Reason for Leaving Company:(Required)Can a representative from our company contact your most recent employer?(Required) Yes No Job 2Name of Business/Employer: Job Title/Position: Employment Dates:Start [MM/YY] Employment Dates:End [MM/YY] Phone/Email: Location: Person to Contact Position in Company Reason for Leaving Company:Can a representative from our company contact your most recent employer? Yes No TRANSPORTATIONDo you curently hold a driver's licence? Yes No What is your current mode of transportation? Driver's Licence Number# Location where the licence was issued Licence Expiration Date MM slash DD slash YYYY Would you willing to provide a driving record? Yes No Any driving accidents in the past three years? Yes No How many? If yes, please explain:Any driving violations in the past three years? Yes No How many? If yes, please explain:COMMUNICATIONCheck the technology devices that you use:(Required) Cell Computer Tablet Do you have a data plan on your mobile device?(Required) Yes No Will you be willing to fill out a caregiver daily checklist after each visit?(Required) Yes No Additional Notes:PERSONAL REFERENCE CONTACTS (Excluding family members)Reference 1Name: Connection: Phone:Email Have they been notified that they are a reference? Yes No Reference 2Name: Connection: Phone:Email Have they been notified that they are a reference? Yes No EDUCATION INFORMATIONList of Qualifications(Required)LEVEL OF EDUCATIONNAME OF SCHOOLPROGRAMCOMPLETED [Yes / No] Add RemoveCRIMINAL BACKGROUNDHave you ever been charged with a criminal offence?(Required) Yes No Are you willing to go through a background check?(Required) Yes No If so, please explain:PLEASE READ CAREFULLYI authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the employer permission to contact schools, previous employers (unless otherwise indicated), and references. This is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, or age. We assure you that your opportunity for this employment position depends solely on your qualifications.