APPLICATION FORM

Upon hire, you must provide proof of your identity, social insurance number and valid work permit if applicable

Mention your employment history below in the following format: Company Name Company Phone Company City / Province Title Employment dates (From / To) Reason for leaving Responsibilities and duties

I hereby certify that the information herein provided in this Employment Application is true and complete to the best of my knowledge. I understand that false statements or omissions may disqualify me from employment, or if employed, cause my dismissal without notice and/or severance. It is understood and agreed that my employment is subject to satisfactory references and criminal record checks. Champ Health Care is authorized to obtain employment references and make inquiries concerning the information given herein and I agree to release any person or organization from liability for the consequences of answers to such enquiries. I hereby release Champ Health Care Services from any liability associated with the provision of references related to my employment at Champ Health Care Services, during my employment or thereafter. Personal information related to the recruitment and hiring process is collected under the authority outlined in the Personal Information Protection and Electronic Documents Act (PIPEDA, Canada 2004). This information will be used to determine eligibility for employment with Champ Health Care Services. The use and disclosure of personal information by Champ Health Care is in accordance with PIPEDA. If you have any questions about the collection, use or disclosure of personal information, please e-mail our Privacy Officer at info@champhealthcareottawa.com