First Name *

Last Name *

Unit

Street Address *

City *

Province *

Postal Code *

Phone *

Email *

Are you legally entitled to work in Canada * YesNo

Are you of legal working age? * YesNo

Do you have a valid Saskatchewan Driver's License? * YesNo

Do you have the ability to and are you legally eligible to obtain your Class 4 Driver's License Upon hire? * YesNo

Do you have a respectable and insurable driver's abstract? * YesNo

Do you have a clear criminal record allowing you to be in a field of work with the elderly, vulnerable and youth patients? * YesNo

Position Applied For —Please choose an option—Patient Transfer SpecialistOffice Admin / Appointment Coordinator

Date Available *

Are you looking for? * Full-TimePart-TimeCasual

Have you ever worked in the healthcare industry? * YesNo

If yes, when and where?

Why are you seeking employment with us? *

Describe a customer service experience that blew you away within the last 3 months. What made it so great? *

High School

Location

From

To

Did you graduate? YesNo

Post-Secondary

Location

From

To

Did you graduate? YesNo

Degree / Diploma / Certification:

Special Qualifications: First Aid/CPRMedical First ResponderEmergency Medical ResponderParamedic StudentPCPACPNursing StudentTLRPARTWHMISOther

If 'Other', please describe:

Job #1

Company

Job Title

Supervisor

Location

Phone Number

Start Date

End Date (leave blank if still employed)

Responsibilities

Reason for Leaving

May we contact your previous supervisor for a reference? YesNo

If you have no previous employers, please supply us with two references other than family.

Full Name

Relationship

Company

Phone Number

Full Name

Relationship

Company

Phone Number