I. PERSONAL INFORMATION
Salutation	Mr. Mrs. Miss Ms.
First Name
Middle Name
Last Name
Street Address
City
State / Province
Postal Code
Date of Birth
Social Insurance Number
Telephone
Cell Phone / Pager
Email Address

FURTHER INFORMATION
Position Applied For
Is there any information we would need about your name or use of another name for us to be able to check your work record?
Do you have any relatives who are presently (or have formerly been) employed by us?
How did you hear about us?
Have you ever been convicted of a criminal offense? If yes, please explain:	Yes: No:

II. EDUCATION HISTORY
High School Name
High School Location
College Name
College Degree / Diploma
Other

III. EMPLOYMENT RECORD (PLEASE INCLUDE ALL EMPLOYMENT FOR THE LAST FIVE YEARS)
1. Company Name (Most Recent Employer)
Position Held
Address
Dates Employed	From: To:
Manager / Supervisor
Telephone
Wage / Salary
Reason for Leaving
2. Company Name (Most Recent Employer)
Position Held
Address
Dates Employed	From: To:
Manager / Supervisor
Telephone
Wage / Salary
Reason for Leaving
3. Company Name (Most Recent Employer)
Position Held
Address
Dates Employed	From: To:
Manager / Supervisor
Telephone
Wage / Salary
Reason for Leaving

IV. REFERENCES (PLEASE DO NOT INCLUDE RELATIVES OR FORMER EMPLOYERS)
1. Name
Years Known
Address
Telephone
Occupation
2. Name
Years Known
Address
Telephone
Occupation
3. Name
Years Known
Address
Telephone
Occupation

V. WORK AVAILABILITY
1. If your application receives favorable consideration, when will you be available to begin work?	Yes: No:
2. Do you have any objection to working overtime?	Yes: No:
3. Can you work overtime without prior notice?	Yes: No:
4. Can you work on Saturday?	Yes: No:
5. Can you work on Sunday?	Yes: No:
6. Can you travel if required by this position?	Yes: No:
7. Have you yet to personally leave your resume with someone in our facility?	Yes: No:    If Yes, who did you leave it with?

VI. Salary / Hourly Rate Requirements
If your application receives favorable consideration, what salary/hourly rate would you require?	$ Per: