The Salvation Army POSITION APPLIED FOR   WAGES EXPECTED  
DINSDALE PERSONAL CARE HOME    
510 - 6th Street, Brandon, MB  R7A 3N9     (204) 727-3636 DATE AVAILABLE  
 
APPLICATION FOR EMPLOYMENT   (Please Print or Type)          
SURNAME   FIRST   MIDDLE   PHONE        
   
ADDRESS   STREET   CITY/TOWN   PROV.   POSTAL CODE    
         
EDUCATION RECORD                
    SCHOOL NAME/ADDRESS FROM TO MAJOR SUBJECT DIPLOMA/DEGREE AWARDED
SECONDARY SCHOOL                
                   
                  Title:  
BUSINESS, TRADE OR                  
TECHNICAL SCHOOL                
                  Title:  
COMMUNITY COLLEGE                  
                   
                  Title:  
UNIVERSITY                    
                   
                  Title:  
ADDITIONAL COURSES, SEMINARS, WORKSHOPS:              
   
   
                     
DESCRIBE ANY OF YOUR WORK RELATED SKILLS, EXPERIENCE, OR TRAINING THAT IS RELATED TO THE POSITION BEING APPLIED FOR: LANGUAGE
  Spoken Written
                  English  
                     
    French  
                     
                  Other  
       
                     
EMPLOYMENT RECORD (MOST RECENT FIRST)            
COMPANY NAME       Employed from: Present/Last PRESENT/LAST JOB TITLE    
      Salary    
          To: $    
ADDRESS                    
    Type of Business: DUTIES/RESPONSIBILITIES    
                 
REASON FOR LEAVING       Supervisor:      
           
                     
COMPANY NAME       Employed from: Present/Last PRESENT/LAST JOB TITLE    
      Salary    
          To: $    
ADDRESS                    
    Type of Business: DUTIES/RESPONSIBILITIES    
                 
REASON FOR LEAVING       Supervisor:      
           
                     
COMPANY NAME       Employed from: Present/Last PRESENT/LAST JOB TITLE    
      Salary    
          To: $    
ADDRESS                    
    Type of Business: DUTIES/RESPONSIBILITIES    
                 
REASON FOR LEAVING       Supervisor:      
           
                     
COMPANY NAME       Employed from: Present/Last PRESENT/LAST JOB TITLE    
      Salary    
          To: $    
ADDRESS                    
    Type of Business: DUTIES/RESPONSIBILITIES    
                 
REASON FOR LEAVING       Supervisor:      
           
                     
HAVE YOU EVER BEEN EMPLOYED BY THIS FACILITY BEFORE?   WHAT SOURCE REFERRED YOU TO THIS FACILITY?    
               
  If Yes     WILL YOU WORK SHIFT WORK?        
      Date From Date To            
MAY WE CONTACT YOUR PRESENT EMPLOYER?              
   
                     
OUTSIDE HOBBIES AND INTERESTS, SERVICE CLUBS OR PROFESSIONAL ASSOCIATIONS:  DO NOT LIST CLUS OR ORGANIZATIONS OF 
A RELIGIOUS, RACIAL, POLITICAL OR NATIONAL CHARACTER.            
                     
                     
                     
                     
                     
                     
REFERENCES                  
LIST TWO PERSONS TO WHOM WE MAY REFER (NOT RELATIVES OR PREVIOUS EMPLOYERS) OFFICE USE ONLY
NAME     ADDRESS       TELEPHONE      
                     
OCCUPATION                    
                     
NAME     ADDRESS       TELEPHONE      
                     
OCCUPATION                    
                     
I HEREBY DECLARE THAT THE FOREGOING INFORMATION IS TRUE AND COMPLETE TO MY KNOWLEDGE.        
I UNDERSTAND THAT A FALSE STATEMENT MAY DISQUALIFY ME FROM EMPLOYMENT, OR CAUSE MY DISMISSAL, I FURTHER UNDERSTAND  
THAT IF THIS POSITION REQUIRES A SPECIFIC CERTIFICATE, PROOF THEREOF WILL BE REQUIRED AFTER HIRE.  
   
SIGNATURE:           DATE:        
                     
FOR OFFICE USE ONLY
INTERVIEWERS COMMENTS:                  
                     
                     
                     
                     
                     
                     
                     
                     
                     
                     
                     
   
         
              INTERVIEWER
                     
THIS SECTION TO BE COMPLETED ONLY IF APPLICANT HAS BEEN HIRED
SOCIAL INSURANCE # IN CASE OF EMERGENCY NOTIFY:            
    NAME:  
                PHONE #    
    ADDRESS:    
DATE OF BIRTH      
    PHONE #    
    FAMILY DOCTOR:            
DD/MM/YYYY                  
MARITAL STATUS   Other:          
       
       
                     
DATE HIRED DEPARTMENT RATE/HR REG. HOURS POSITION DATE EMPLOYMENT
                COMMENCED