Personal Data

Email address:

          
Enter your certificate of competence number or your registration number as issued by your governing body. # Year
Verified by:

Have you previously worked at The Brantford General Site or the Willett Site?      
Yes        No

If yes, give year(s) and position

Are you eligible to work in Canada?    Yes         No

Education
Elementary or Secondary School
Highest Grade or Level Completed        
Type of Certificate or Diploma Obtained

Business, Trade or Technical School
Name of Course Length of Course
License, Certificate or Diploma Awarded

Community College
Name of Program Length of Program
Diploma Received  Yes   No
Other Courses, Workshops, Seminars
 

University
Length of Course
Degree awarded   Yes     No             Pass         Honours

Major Subject

Licenses, Certificates, Degrees 

Work Related Skills
(Describe your work related skills, experience, or training that relate to the position being applied for.) 

Employment (Beginning with most recent employment)
Name and Address of Present/Last Employer:
Type of Business        
Present/Last Job Title 
Period of Employment - From to
Present/Last Salary    
Name of Supervisor     Phone
Reason for Leaving    

Name and Address of Previous Employer:
Type of Business    
Previous Job Title   
Period of Employment - From to
Final Salary           
Name of Supervisor Phone
Reason for Leaving 

Name and Address of Previous Employer:
Type of Business     
Previous Job Title    
Period of Employment - From to
Final Salary            
Name of Supervisor  Phone
Reason for Leaving 

For employment references, may we approach:
Your Present/Last Employer - Yes     No
Your Former Employer(s)? -   Yes     No

List references if different than above

List all other employers

Volunteer Work Experience

Have you ever been convicted of a criminal offence for which a pardon has not been granted?

Other Data
It is the responsibility of this Hospital to protect its patients and staff from any disease or infection which might be brought in by new members of the staff. For this reason all new personnel must, as a condition of employment, pass medical examinations as required by the Hospital, in accordance with the Public Hospitals Act and other legislative acts. Repeat examinations as required by legislation or the Hospital are mandatory.
WOULD YOU CONSENT TO A HEALTH REVIEW?    Yes      No

I hereby certify that the facts set forth in the above employment application and support employment documentation are true and complete to the best of my knowledge. I understand that if employed, falsified statements or any overt omissions on this application form or any other support employment documentation (resume) shall be considered sufficient cause for dismissal. I shall not disclose or use, during or subsequent to my employment with the Brant Community Healthcare System, any confidential information or data without first obtaining written consent of the Brant Community Healthcare System.
Date:     I understand and agree - Yes      No

Release of Information Authorization
I hereby authorize the Brant Community Healthcare System to contact any of my present or previous employers to make any inquiries usually required to determine my suitability for employment.
Date:     I understand and agree - Yes      No