Position Applying For (Please Select one)

Personal Support WorkerHealth Care AideRegistered Practical NurseRegistered Nurse

Last or Family Name(Required):

First Name:

Middle Name:

Street Address and Number:

Apt#:

City:

Province:

Email:

What is your Major Intersection?

Home Tel:

Mobile Ph:

Date of Birth:

Social Insurance Number:

Are you legally entitled to work in Canada? : YesNo

Are you bondable?: YesNo

Have you ever been convicted of a crime for which a pardon has NOT been granted?: YesNo

Do you have a car? : YesNo

COMMUNICATION: Please check or name the languages you can communicate in the most fluently
English: ReadWriteSpeak
French: ReadWriteSpeak
Italian: ReadWriteSpeak
Others:
Do you have a current certification in FIRST AID/ CPR? YesNo

EDUCATION:
Name of Course:
Institution:
Length of course:
Year Completed :
Finished Program: YesNo
OTHER EDUCATION: (include courses/programs from other Provinces or Countries where applicable)
Name of Course :
Institution:
Year of Completion:
Name of Course2:
Institution:
Year of Completion:
Name of Course2:
Institution:
Year of Completion:
EMPLOYMENT
Name of Employer :
Address:
Tel:
Position Held:
Date Employed :
From : To:
Supervisor:
Duties:
Reason for Leaving:
May we contact this person for reference purposes? :YesNo
Name of Employer - 2 :
Address:
Tel:
Position Held:
Date Employed :
From : To:
Supervisor:
Duties:
Reason for Leaving:
May we contact this person for reference purposes? :YesNo
Name of Employer - 3 :
Address:
Tel:
Position Held:
Date Employed :
From : To:
Supervisor:
Duties:
Reason for Leaving:
May we contact this person for reference purposes? :YesNo
References: (no family members or friends please)

Name of reference:
Relationship:
Organization/Address:
Tel:

Name of reference2:
Relationship:
Organization/Address:
Tel:

PLEASE READ CAREFULLY AND TYPE YOUR NAME BELOW:

TERMS AND CONDITIONS
1. (hereinafter referred to as “YOU”, “YOUR”, “I”, “ME” or “MY”) are an employee of Nu Age Health Care O/U 1074938 Ontario Inc. (hereinafter referred to as NU AGE HEALTH CARE”) and will be sent to Homes & Health care settings to work (hereinafter referred to as “FACILITIES” or “FACILITY”). YOUR relationship with NU AGE HEALTH CARE is entered into as an elect to work arrangement and YOU have the right to decline work without penalty. YOU acknowledge that YOU will not receive termination pay.

2. YOUR working hours will be recorded on an NU AGE HEALTH CARE time slip. YOUR time slip must be signed by an authorized representative at the FACILITY where YOUR shift was completed. The time sheet is YOUR responsibility and must be completed and forwarded to NU AGE HEALTH CARE at the end of each pay period. If YOU cannot do so, YOU must contact NU AGE HEALTH CARE to prevent from not being paid and waiting an extra pay period for getting paid.

3. Pay periods are biweekly on Friday.

4. Should any FACILITY that YOU have worked with offers YOU a position, YOU can only accept that position after YOU have worked with for a minimum period of three (3) months, unless otherwise agreed upon between YOU and NU AGE HEALTH CARE.

5. If YOU feel that any assignment at a FACILITY that YOU have been asked to perform is not safe, YOU should report this matter immediately to YOUR onsite supervisor also call NU AGE HEALTH CARE supervisor and notify NU AGE HEALTH CARE in writing.

6. No alcohol or drugs will be tolerated before or while YOU are at a FACILITY or while on assignment.

7. In case of a personal injury at a FACILITY, YOU must fill out an incident report to the FACILITY SUPERVIOSR also call NU AGE HEALTH CARE supervisor and notify NU AGE HEALTH CARE in writing within twenty-four (24) hours of the incident.

8. All notices to NU AGE HEALTH CARE must be sent to:
Nu Age Helath Care, 310-200 James Street South, Hamilton,On L8P-3A9.

I hereby certify that the facts and statements made by me on this application are true and correct to the best of my knowledge, information and belief. This information may be used to neccasary clearances & references.

I certify that I have read and understood the Terms and Conditions of this agreement and realize that failure to comply may result in the termination of my employment with Nu Age Health Care.

I understand that, if employed, false statements on this application shall be considered sufficient cause for legal action.

I AGREE WITH THE ABOVE STATEMENT. Agree

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