Employment Application Form - Nexim Healthcare

NEXIM HEALTHCARE CONSULTANTS INC.

Prospect Screening Questions

Candidate’s name:

Position:
RNRPNPSWDSW/SSW

Cell Phone number:

Alternative number:

Email address:

Candidate's address (City):

Are you age 18 or older?
YesNo

Are you legally entitled to work in Canada?
YesNo

Have you ever been convicted of a criminal offense for which a pardon has not been granted? YesNo

Are you comfortable working around pets? YesNo

What date are you available to start work?

Do you have a G driver's license?
YesNo

Do you have access to a reliable vehicle?
YesNo

What is your availability

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Day shift
Afternoon shift
Overnight shift

Where did you receive your diploma/certificate?

Do you have a medical pharmacology certificate? YesNo

Issue Date:

Do you have your CPR (level C) standard first aid? YesNo

Issue Date:

Do you have CPI crises prevention intervention?
YesNo

Issue Date:

Do you have a vulnerable Sector Police record check for employment? YesNo

What was the date of your last record check?

Please provide three employment related references, including your current supervisor.

In addition to the references provided by the applicant, the Company reserves the right to
contact others who it deems relevant and appropriate in the assessment of this application.

Name and Title Employment Relationship Company and Phone Number

Reference 1

Name and Title Employment Relationship Company and Phone Number

Reference 2

Name and Title Employment Relationship Company and Phone Number

Reference 3