| Position Applying For: |
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| Personal Information |
| First Name: |
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| Last Name: |
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| Address Line 1: |
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| Address Line 2: |
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| City: |
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| Province/State: |
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| Country: |
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| Postal/Zip Code: |
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| Home Phone: |
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| Cell: |
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| Pager: |
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| Message Phone: |
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| E-mail Address: |
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| Liability Insurance |
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If you are an RN or LPN, are you presently licensed
to work within the Province of Nova Scotia?
Yes
No
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Can a copy of your RN or LPN be provided?
Yes
No
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We are required to ask the following questions
by liability insurance providers: |
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1. Have you ever been the recipient of any
allegations of professional negligence in writing or verbally?
Yes
No
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2. Are you aware of any facts, circumstances or situations
which may reasonably give rise to a claim related
to your professional practice; other than advised above?
Yes
No
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3. Have you ever been suspended, prohibited
from practicing or the recipient of a disciplinary complaint?
Yes
No
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| If you answered yes to any of the above, please provide details: |
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Have you be convicted of a criminal offense
that has not yet been pardoned?
Yes
No
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| If yes, please explain details: |
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Can a copy of your Record of Conduct be provided?
Yes
No
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Previous Work History or Volunteer Work
Please list your three most recent employers |
Organization:
Phone No.
Supervisor:
Title:
Duties:
From:
To:
Reason for Leaving:
May we contact for reference?
Yes
No
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Organization:
Phone No.
Supervisor:
Title:
Duties:
From:
To:
Reason for Leaving:
May we contact for reference?
Yes
No
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Organization:
Phone No.
Supervisor:
Title:
Duties:
From:
To:
Reason for Leaving:
May we contact for reference?
Yes
No
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| Education |
Have you completed High School?
Yes
No
If no, number of years completed:
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Please feel free to list any other information
that you feel will be helpful in placing you
into employment opportunities (i.e. additional courses, awards, etc.)
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| Verification |
Recognizing the importance of trust in an employee relationship and that
HealthStaff will be relying on the information which I have provided to the company, I:
- Authorize the verification of the above information and any other necessary
inquiries which may be needed to determine my suitability for employment.
- Affirm that the above information is true to the best of my knowledge.
- Am able to meet the physical and mental demands of the position.
- Acknowledge that misrepresenting or supplying false/inaccurate information may
result in immediate rejection of my application or result in dismissal for cause.
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| Applicant's Signature: |
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| Date: |
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*By digitally signing (typing your name) this form,
you are verifying that all the information you have provided
is true, correct, and complete. |
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