First Name: Last Name:
Phone Number: Date Of Birth:
Address: Postion Applied For:
Email: Class of License
Education: (highest grade) Secondary Education
How did you hear about the position? What is your hourly rate expectation ($)
Are you capable of lifting up to 65 lb. on a constant basis? Yes No
Are you aware of any health problem that would preclude you from performing the duties of your job? Yes No
Are you willing to undergo a job-related Medical Examination by a Physician selected by this company? Yes No
(If applicable) Are you Bondable? Yes No
Are you legally entitled to work in Canada? Yes No
Do you have any objection to providing abstracts of your driving record on request? Yes No
Have you been in any automobile accidents during the last 3 years? Yes No
If yes how many?
Do you have any traffic convictions? Yes No
If yes, please list them below:
1.
2.
3.
List any certificates / safety training (Ex. WHMIS) and expiry dates that may pertain to this job
1.
2.
3.
4.
Name your 3 previous employers, if applicable:
Company:
Address: City:
Province: Postal Code:
Contact Name: Phone #:
Start Date: End Date:
Position Held: Salary / Wage:
 
Company:
Address: City:
Province: Postal Code:
Contact Name: Phone #:
Start Date: End Date:
Position Held: Salary / Wage:
 
Company:
Address: City:
Province: Postal Code:
Contact Name: Phone #:
Start Date: End Date:
Position Held: Salary / Wage:
Upon submitting this form, I agree that all the information provided is true to the best of my knowledge.