Personal Information
First Name:
 Middle Name.:
 Last Name:
Date of Birth:
(DD/MM/YYYY)
Country of Citizenship:
 Do you have a passport/visa?:
Home Phone:
 Business Phone:


Address (Present):

Street Address:

 City:
 Province:
Postal Code:
Term of Residence: years


Address (Previous):

Street Address:

 City:
 Province:
Postal Code:
Term of Residence: years


Address (Mailing):

Street Address:

 City:
 Province:
Postal Code:
Term of Residence: years


Emergency Contact Person:

Phone Number:
Street Address:

 City:
 Province:



Education

Highest level of grade school (1-13):
Last Year of attendance: 		Name of last school attended:
Name of Institution:
Date Attended
From Mo / Yr to Mo / Yr
Month/Year left
or Graduated 		Type of Degree Earned Major Subject Class Standing



Physical

Are you physically able to do heavy lifting? Yes: No:
If no, explain:


List any physical limitations: (eyes, limb/back impariments, hearing, etc)


Date of last physical exam:

Doctor's Information: (Name, Address, Phone)


If you've ever been injured on the job, please explain:


How much time in the last 3 years have you missed due to illness?:


Have you recieved Worker's Compenstation? If so, when?


Driver's Licence

Operator Licence Number:

Date of Expiration:


Issuing Province:



Type of Licence:
   A:    B:    C:
  Class:
   1:    2:    3:    4:    5:    6:
  Air Ticket: Yes: No:

How many current demerits do you have?:

How many moving violations have you recieved in the last 2 months?:

Has your operator licence been suspended during the past 2 years and if so, why?


Employment Guidelines:

Driver's Abstract Maximum 6 demerit points, NO DUIs or drug related violation.

If upon receipt of Driver's Abstract we find that it does not meet the
above conditions, we reserve the right to terminate your employment
without notice.

Employment History:


Employer 1:
Employer:
 Contact Name:
 Phone Number:
Address:
 City:
Province/State:
 Country:
 Postal Code/Zip:
Date of employment:
From: (mm/yyyy)
To: (mm/yyyy)
Position:
Salary/Wage:
Reason for leaving:


Employer 2:
Employer:
 Contact Name:
 Phone Number:
Address:
 City:
Province/State:
 Country:
 Postal Code/Zip:
Date of employment:
From: (mm/yyyy)
To: (mm/yyyy)
Position:
Salary/Wage:
Reason for leaving:


Employer 3:
Employer:
 Contact Name:
 Phone Number:
Address:
 City:
Province/State:
 Country:
 Postal Code/Zip:
Date of employment:
From: (mm/yyyy)
To: (mm/yyyy)
Position:
Salary/Wage:
Reason for leaving:


Employer 4:
Employer:
 Contact Name:
 Phone Number:
Address:
 City:
Province/State:
 Country:
 Postal Code/Zip:
Date of employment:
From: (mm/yyyy)
To: (mm/yyyy)
Position:
Salary/Wage:
Reason for leaving:


Employer 5:
Employer:
 Contact Name:
 Phone Number:
Address:
 City:
Province/State:
 Country:
 Postal Code/Zip:
Date of employment:
From: (mm/yyyy)
To: (mm/yyyy)
Position:
Salary/Wage:
Reason for leaving:


I confirm that all information in this submission is truthful and accurate:
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