Application Form

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

Province

Postal Code *

Driver's License Number

Section 1 - General Information

Position Applying For (required)

How did you hear about us? (required)

Do you speak another language other than English?

Yes No

What other language(s) are you fluent in?

Section 2 - Credentials

Which credential is MOST valid? (required)

Are you a member of the Ontario Personal Support Workers Association? (required)

Yes No

How many doses of the COVID-19 vaccine have you had? (required)

(Numeric Answer Only)

Are you currently certified in CPR and First Aid? (required)

Yes No

Have you had a Vulnerable Sector Police Check done in the last 6 months? (required)

Yes No

Have you had a Tb test in the last 24 months? (required)

Yes No

Have you had this seasons Influenza vaccine? (required)

Yes No

Section 3 - Employment Information

What date are you available for Employment? (required)

Are you a driver with a vehicle you can use to get to work? (required)

Yes No

Have you previously applied for a position at Comfort Keepers of Brampton/North Mississauga? (required)

Yes No

Have you ever worked for a Comfort Keepers location in the past? (required)

Yes No

Do you have any relatives currently employed by Comfort Keepers of Brampton/North Mississauga or Comfort Keepers Canada? (required)

Yes No

Are you legally able to work in Canada? (Proof of eligibility will be required before you can be employed.) (required)

Yes No

Have you ever been convicted of a crime for which you have not received a full pardon? (required)

Yes No

Section 4 - Experience

Do you have experience in community care? (required)

Yes No

Do you have experience in long term care? (required)

Yes No

Do you have experience in retirement homes? (required)

Yes No

Please list the medical conditions you have experience with (required)

What PSW skills do you have experience with? (required)

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Section 5 - Resume

Please use this space to copy and paste your CURRENT resume, or a portion thereof. Submission of a resume is not an alternative to completing this application form. Only complete applications will be considered. You may also choose to add comments and other Skills, licenses/certification and qualifications (including explanation of any gaps in employment)

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Section 6 - Availability

Monday (required)

Tuesday (required)

Wednesday (required)

Thursday (required)

Friday (required)

Saturday (required)

Sunday (required)

Section 7 - Reference 1

Name:

Telephone Number

(Numeric Answer Only)

Years Known

(Numeric Answer Only)

Relationship

Section 8 - Reference 2

Name:

Telephone Number

(Numeric Answer Only)

Years Known

(Numeric Answer Only)

Relationship

Section 9 - Reference 3

Name:

Telephone Number

(Numeric Answer Only)

Years Known

(Numeric Answer Only)

Relationship

Section 10 - Applicants Certification and Agreement

I certify that the facts contained in this application are true and complete. I understand that any misrepresentation or falsification of information or significant omissions may carry penalties applicable to my application or employment with Comfort Keepers if discovered at a later date. (required)

Yes No

I understand that, if employed, my employment is not guaranteed for any term, and my employment may be terminated by the employer or myself at any time and for any reason with or without prior notice. (required)

Yes No

If I am employed, I agree to comply with and be bound by the safety and health rules and regulations, and rules of conduct of Comfort Keepers. (required)

Yes No

This application will remain on active file for 60 days. If I am hired within this period, this form will be transferred to my individual personnel file. If I am not hired or have not heard from this employer within 60 days, this application is no longer active and I will need to reapply for employment if I wish to be considered for a job with Comfort Keepers. (required)

Yes No

I give the employer and /or its agents, including consumer reporting bureaus, the right to investigate any and all statements made in this application for the purpose of employment and retention of employment. This investigation may include, but not limited to, credit reports, criminal conviction records, motor vehicle driving records and previous employment history. Further, I hereby release from liability and hold harmless this employer, its representatives, all persons and organizations/companies for furnishing such information. (required)

Yes No

If required, I agree to a drug testing prior and during employment or for post incident investigations. (required)

Yes No

The employer, Comfort Keepers, is an Equal Opportunity Employer. The employer does not discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicants consideration for employment on a basis prohibited by local, provincial, or federal law. (required)

Yes No

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

Signature

Brampton/Mississauga North Application Form

Personal Information

Section 1 - General Information

Section 2 - Credentials

Section 3 - Employment Information

Section 4 - Experience

Section 5 - Resume

Section 6 - Availability

Section 7 - Reference 1

Section 8 - Reference 2

Section 9 - Reference 3

Section 10 - Applicants Certification and Agreement