Work History

(past 7 years – most recent first)

Employer Name *

Employer Address *

Employer Phone *

Date Started *

Date Left *

Starting Salary (per hour) *

Leaving Salary (per hour) *

Starting Position *

Leaving Position *

Description of Duties

Reason for Leaving

#2 Employer Name *

Employer Address *

Employer Phone *

Date Started *

Date Left *

Starting Salary (per hour) *

Leaving Salary (per hour) *

Starting Position *

Leaving Position *

Name & Title of Supervisor

Description of Duties

Reason for Leaving

#3 Employer Name *

Employer Address *

Employer Phone *

Date Started *

Date Left *

Starting Salary (per hour) *

Leaving Salary (per hour) *

Starting Position *

Leaving Position *

Name & Title of Supervisor

Description of Duties

Reason for Leaving

In addition to your work history, what other experiences, skills or qualifications should we know about that would pertain to the position you are applying for.

Character References

#1 Name *

First

Last

#1 Address *

#1 Phone *

#2 Name *

First

Last

#2 Address *

#2 Phone *

#3 Name *

First

Last

#3 Address *

#3 Phone *

I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the statements checked unless I have indicated to the contrary. I authorize the references listed above and other individuals who you may contact to provide any and all information concerning my previous employment and any other pertinent information that they may have. Furthermore, I release all parties and persons from any and all liability for damages that may result from furnishing such truthful information as well as from the disclosure of such information by the employer or any of its agents, employees, or representatives. I understand that any misrepresentation, falsification or material omission of information on this application may result in my failure to receive an offer or, if I am hired, my dismissal from employment. In consideration of my employment, I agree to conform to the rules and standards of the practice, as amended from time to time in its discretion. I further agree that my employment and compensation can be terminated at will, with or without cause, and with or without notice, at any time, either at my option or at the option of the employer. I understand that no employee or representative of the practice other than its owner(s) has the authority to enter into agreement for employment for any specified period of time or to make any agreement contrary to that stated in this form. Furthermore, the owner(s) of the practice may not alter the at-will nature of the employment relationship unless he/she/they does(do) so in writing. I also understand that all offers of employment are conditioned on the provision of satisfactory proof of an applicant’s identity and legal authority to work in the Canada. *

I Agree and Understand

Signature

Clear Signature

Date *

EMPLOYMENT APPLICATION

Education

Work History

Character References

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Location

Hours

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