Online Application

Position Applying For: (Please Select One )
Personal Support Worker Health Care Aide	Registered Practical Nurse Registered Nurse

Last or Family Name	First Name	Initials

Street Address and Number	Apt#	City

Province	Postal Code	Email

What is your Major Intersection?

Home Telephone	Cell Phone

Date of Birth (mm/dd/yy)	Social Insurance Number

Are you legally entitled to obtain employment in Canada?
Yes No
Are you bondable?
Yes No
Have you ever been convicted of a crime for which a pardon has NOT been granted?
Yes No
Do you have a car ?
Yes No

Communication : Please check or name the languages you can communicate in the most fluently
	Read	Write	Speak
English
French
Italian
Other:
Do you have a current certification in FIRST AID/ CPR?
Yes No

Education
Name of Course	Institution

Length of Course	Year Completed	Finished Program:
		Yes No
Other Education *(include courses/programs from other Provinces or Countries where applicable)*
Name of Course	Institution	Year of Completion

Employment
Name of Employer	Address	Telephone Number

Position Held	Dates Employed	Supervisor
	to
Duties

Reason for leaving

May we contact this person for reference purposes?		Rate of Pay
Yes No

Name of Employer	Address	Telephone Number

Position Held	Dates Employed	Supervisor
	to
Duties

Reason for leaving

May we contact this person for reference purposes?		Rate of Pay
Yes No
Name of Employer	Address	Telephone Number

Position Held	Dates Employed	Supervisor
	to
Duties

Reason for leaving

May we contact this person for reference purposes?		Rate of Pay
Yes No

References: (no family members or friends please)
Name of reference	Relationship	Organization/Address	Telephone Number


PLEASE READ CAREFULLY AND TYPE YOUR NAME BELOW: TERMS AND CONDITIONS 1. (hereinafter referred to as “YOU”, “YOUR”, “I”, “ME” or “MY”) are an employee of Everest Nursing and Community Care Agency Inc. (hereinafter referred to as “EVEREST”) and will be sent to Home and Health Institutions to work (hereinafter referred to as “FACILITIES” or “FACILITY”). YOUR relationship with EVEREST is entered into as an elect to work arrangement and YOU have the right to decline work without penalty. YOU acknowledge that YOU will not receive termination pay. 2. YOUR working hours will be recorded on an EVEREST time sheet. YOUR time sheet must be signed by an authorized representative at the FACILITY where YOUR shift was completed. The time sheet is YOUR responsibility and must be completed and forwarded to EVEREST at the end of each week. If YOU cannot do so, YOU must contact EVEREST no later than the following Monday morning. This will prevent waiting an extra pay period for YOUR pay. 3. Pay periods are biweekly on Friday. 4. Should any FACILITY that YOU have worked with offers YOU a position, YOU can only accept that position after YOU have worked with EVEREST for a minimum period of three (3) months, unless otherwise agreed upon between YOU and EVEREST. 5. If YOU feel that any assignment at a FACILITY that YOU have been asked to perform is not safe, YOU should report this matter immediately to YOUR onsite supervisor and also immediately notify EVEREST in writing. 6. No alcohol or drugs will be tolerated before or while YOU are at a FACILITY. 7. In case of a personal injury at a FACILITY, YOU must fill out an incident report at the FACILITY and also notify EVEREST in writing within twenty-four (24) hours of the incident. 8. All notices to EVEREST must be sent to: Everest Nursing & Community Care Agency Inc. 2341 Nikanna Road, Mississauga, ON L5C 2W8 I hereby certify that the facts and statements made by me on this application are true and correct to the best of my knowledge, information and belief. This information may be used to obtain a Fidelity Bond. I certify that I have read and understood the Terms and Conditions of this agreement and realize that failure to comply may result in the termination of my employment with EVEREST. I understand that, if employed, false statements on this application shall be considered sufficient cause for legal action. Signature: Date: