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.
BY PRESSING "SUBMIT" YOU CERTIFY THAT ALL INFORMATION IS TRUE AND ACCURATE
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