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Employment Application

This application is designed to help both you and us if you are employed by us. The information contained in this application will help us understand you as a person, your needs, your career goals, and your interests. The information you give will be treated as confidential and will not be made public.

"Consideration for employment is based solely on qualifications without regard to race, colour, religion, age (except where defined by law), sex, marital status, ancestry, place of origin, physical disability, or political beliefs."

Please Note: Bolded items are required.

GENERAL DATA
Date of Application: February 23, 2012
Surname:* First:* Middle: Do you have a SIN number?
YES NO
Home Phone:* Cell/Other Phone: Email Address:
Address: City or Town: Province: Postal Code:
Previous Address in Canada? Dates you lived there?
How will you travel to work? Do you have a valid driver's licence? YN
If Yes, what Province? 		Are there any outstanding warrants for your arrest in any jurisdiction?*
YN
Do you have any outstanding fines?
YN		 Have you ever been convicted of a criminal offence?*YN Are you presently under investigation for any criminal offence? YN
Are you 19 years of age or over?
YN		 Where did you learn of the position you are applying for?
Relatives or Friends Working for this company? Name: Relationship: Phone No.:


EDUCATION
NAME OF SCHOOL LOCATION OF SCHOOL ATTENDED TYPE OF
COURSE		 HIGHEST GRADE /
LEVEL COMPLETED
FROM TO
High School:
Month Year Month Year
Month Year Month Year
Month Year Month Year
Month Year Month Year
College:
University:
Business or Vocational:
Official Languages Spoken: Official Languages Written: Are you a Student? Where are you enrolled?
YES  NO
Do you have any security training? If yes, please explain:
YES  NO
Do you have training in any of the following? (Please check all that apply)
WHIMIS CPR First Aid CPR/First Aid Expiry Date:
Describe any additional skills below:
Present or past memberships in groups:
(Please do not list organizations that indicate race, color, age, religion, sex, marital status, ancestry, physical disability or political beliefs)


PROFESSIONAL REFERENCES (Other than Relatives)
Name: Business or Home Address: Business or Home Phone Number:
1.
Name: Business or Home Address: Business or Home Phone Number:
2.
Name: Business or Home Address: Business or Home Phone Number:
3.


POSITION APPLIED FOR Select One: Full-Time Part-Time
Number of hours expected per week: Rate of pay expected: Are you available to work on short notice?
YESNO
Date available for employment: Location preference (if any): Would you be willing to accept a transfer?
YESNO
Are you currently employed? If yes, may we contact your employer? Describe your work ethic:
YESNO YESNO
Are you eligible for permanant employment in Canada? Have you been previously employed by this company? If yes, please provide dates of employment:
YESNO YESNO
Do you have an illness or disability which may resonably preclude
you from the performance of duties for which you are applying?		 Please check the boxes below to specify the shifts that you are able to work:
YESNO Days Evenings Nights Weekends Holidays All
Have you ever been released or discharged from a job? (Include Lay-Offs) If yes, please explain:
YESNO


EMPLOYMENT HISTORY (Please record the last 4 positions beginning with the most recent employer)
Present or Last Employer Employment Dates Title / Position Rate of Pay
Employer Name: From To Start Finish
Month Year Month Year
Employer Address: Supervisor's Name Reason for Leaving
Phone Number: Nature of Duties (Please be specific):

Present or Last Employer Employment Dates Title / Position Rate of Pay
Employer Name: From To Start Finish
Month Year Month Year
Employer Address: Supervisor's Name Reason for Leaving
Phone Number: Nature of Duties (Please be specific):

Present or Last Employer Employment Dates Title / Position Rate of Pay
Employer Name: From To Start Finish
Month Year Month Year
Employer Address: Supervisor's Name Reason for Leaving
Phone Number: Nature of Duties (Please be specific):

Present or Last Employer Employment Dates Title / Position Rate of Pay
Employer Name: From To Start Finish
Month Year Month Year
Employer Address: Supervisor's Name Reason for Leaving
Phone Number: Nature of Duties (Please be specific):

CONSENT
*

I declare that the facts set forth above in my application for employment are true and complete. I understand that if I am employed, false statements on this application shall be sufficient cause for dismissal regardless of seniority or other considerations.
* By selecting the box to the left, you are authorizing Northeastern to conduct a background investigation in order to verify all information.

    


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