APPLICATION FORM

Your name

Your email

Phone

Your address

How did you hear about us?
Employee ReferralIndeedKijijiCareers WebsiteLinkedInNewspaper AdJob BankCareer FairOther (please specify)

Other (Please specify)

Referred By

Have you ever worked with Champ Health Services Canada before?
YesNo

If yes, please specify the dates of employment and your position.

Do you have any relatives working with Champ Health Services?
YesNo

If yes, please specify relative's full name, position and your relation to him/her.

Have you ever convicted any crime for which the pardon has not been granted?
YesNo

When can you start working?
As soon as possibleWithin 2 weeksWithin 4 weeksAfter 4+ weeks

Desired Salary

Employment Type
Full TimePart TimeCasualDaysNightsEveningsWeekends

Work Authorization
(Upon hire, you must provide proof of your identity, social insurance number and valid work permit if applicable)
I'm authorized to work in this country for any employerI'm authorized to work in this country for a specific employerI require sponsorship to work in this countryMy status to work in this country is unknown

Degree or Diploma
High School Diploma / GEDTrade or Technical School DiplomaAssociates DegreeBachelors DegreeMasters DegreePhDOther

School Name

Last Grade / Date Graduated

Any further education details, please share below

Certifications / Licenses

Please mention your employment history below.
(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)

Resume Attachment
(Your resume can be uploaded in any of the following formats: DOC, DOCX, RTF, PDF, TXT, HTML.)

Cover Letter

Disclaimer and Signature
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

Signature (Enter your name)

Date

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