Application Form

 Personal Support Worker Registered Practical Nurse Health Care Aide Registered Nurse

Last or Family Name*

First Name*

Initials

Street Address and Number*

Apt#

City

ProvinceSelect ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

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?

Are you bondable?

Have you ever been convicted of a crime for which a pardon has NOT been granted?

Do you have a car ?

Communication : Please check or name the languages you can communicate in the most fluently

Do you have a current certification in FIRST AID/ CPR?

Education

Name of Course

Institution

Length of Course

Year Completed

Finished Program:

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

Duties

Reason for leaving

May we contact this person for reference purposes?

Rate of Pay

Name of Employer

Address

Telephone Number

Position Held

Dates Employed

Supervisor

Duties

Reason for leaving

May we contact this person for reference purposes?

Rate of Pay

Name of Employer

Address

Telephone Number

Position Held

Dates Employed

Supervisor

Duties

Reason for leaving

May we contact this person for reference purposes?

Rate of Pay

References:

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.