Employment Application Golden Door Geriatric Centre

1679 Pembina Hwy

Winnipeg, MB R3T 2G6

Date

Name

Last First Middle

Present Address

No. Street City Province Postal Code

Telephone No. ( ) Alternate Telephone No. ( )

Position(s) applied for:

Do you want to work: Full-Time Part-time Casual Summer Help

Days Nights Evenings Weekends

Date available to start work?

Have you worked for us before? If yes, when?

Have you ever been employed under a different name? If yes, please specify:

Do you have current CPR or First Aid training? Yes___ No___ Date of last training:

For Nursing Positions (BN/RN/RPN/LPN):

Current valid registrations held, please give provinces and number:

For Health Care Aide Positions: Are you certified? Yes___ No___

For Food Services or Recreation Positions: Do you have a current Food Handler’s Certificate? Yes___ No___

Language

English: Speak Read Write

French: Speak Read Write

Do you speak any other languages? Please specify: ______

PERSON TO BE NOTIFIED IN CASE OF ACCIDENT OR EMERGENCY:

Name: Phone: Relationship:

Education Background

High School / Post Secondary Education / Undergraduate College/University / Graduate
Years Completed / 9 / 10 / 11 / 12 / 13 / 1 / 2 / 3 / 4 / 1 / 2 / 3 / 4 / 1 / 2 / 3 / 4
Diploma/Degree
Other Educational Information

If currently enrolled in an educational program, please state the name of the program and date of anticipated completion:

Prior Work History (List in order, present employer first)

Dates / Name and Address of Employer / Rate of Pay / Supervisor’s Name and Title / Reason for Leaving
From / To / Start / Finish
Dates / Name and Address of Employer / Rate of Pay / Supervisor’s Name and Title / Reason for Leaving
From / To / Start / Finish
Dates / Name and Address of Employer / Rate of Pay / Supervisor’s Name and Title / Reason for Leaving
From / To / Start / Finish
Dates / Name and Address of Employer / Rate of Pay / Supervisor’s Name and Title / Reason for Leaving
From / To / Start / Finish

Employment/Volunteer/Educational References

Name and Occupation / Address / Phone Number
1.
2.
3.

If employed, I agree to abide by the policies, procedures, and working conditions established by the Centre.

I agree to receive an Immunization Status Record completed by a physician and incur any costs related to the completion of any necessary Immunizations. I also agree to provide a current criminal record check at my own expense.

I declare the foregoing information to be true and complete to the best of my knowledge and understand that any misrepresentation or omission may result in my dismissal if I am employed.

I hereby authorize Golden Door Geriatric Centre to contact the above references.

Signature of Applicant: Date: