CONNECT HURONIA

APPLICATION FOR EMPLOYMENT

Date Last name Street Address Telephone Cell Yes First name City

WORKFORCE SOLUTIONS INC.

Middle name Postal Code

Are you a Canadian Citizen or otherwise authorized to work in Canada?

No

Are you looking for full-time employment or are you looking for part-time/temporary employment? (please circle) Date you are available Are you willing to work shift work? Position(s) applied for: How did hear about Connect Huronia? Are you presently employed? Are you available full-time work? Are you available for part-time work? Are you willing to travel? Do you have a car? Do you have a license? Yes Yes Yes No No No Yes Yes No No Yes No Yes What hours are you available? No Are you willing to work all shifts? Desired wage range: Yes No

Have you ever been convicted of a Criminal Offence of which you have not been pardoned? (This will not affect your application) Yes No Have you worked for an employment agency in the past? When Have you ever reported a work related job injury? What was the nature of the injury? Please explain any disabilities or limitations that would prevent you from performing any type of work. Where Yes No When? Yes No

Education High School

School name and location

Year

Grad.

Degree

College / University Other Training Please list any scholastic honors received / certificates, etc.

Employment History (start with the most recent employer) Company Name Address Date started Date ended Name of supervisor Responsibilities Reason for leaving Starting position Ending position May we contact? Yes No Telephone:

Company Name Address Date started Date ended Name of supervisor Responsibilities Reason for leaving Starting position Ending position May we contact? Yes No Telephone:

Company Name Address Date started Date ended Name of supervisor Responsibilities Reason for leaving Starting position Ending position May we contact? Yes No Telephone:

In addition to your work history, are there other skills, qualifications, or experience that we should consider:

References List three references, not related to you, who have known you for more than one year Name Address Name Address Name Address Phone Years Known Phone Years Known Phone Years Known

Emergency Contact: In case of an emergency, please notify the person indicated below for which I also give my permission to contact: Name Address Phone

Please read before signing: I certify that all information provided by me on this application is true and complete to the best of my knowledge. Signature Date