EMPLOYMENT HISTORY: List below, beginning with most recent.
Name & Address of Business:
Telephone: Contact:
Job Title: Employed from (mo./yr.) to
Duties/Responsibilities:
Salary:
Reason for Leaving:
Name & Address of Business:
Telephone: Contact:
Job Title: Employed from (mo./yr.) to
Duties/Responsibilities:
Salary:
Reason for Leaving:
Name & Address of Business:
Telephone: Contact:
Job Title: Employed from (mo./yr.) to
Duties/Responsibilities:
Salary:
Reason for Leaving:
Name & Address of Business:
Telephone: Contact:
Job Title: Employed from (mo./yr.) to
Duties/Responsibilities:
Salary:
Reason for Leaving:
REFERENCES
Name Address Relationship Telephone
CERTIFICATION
My signature on this application certifies that the above information is true. My signature also authorizes Kings Regional
Rehabilitation Centre to conduct any necessary inquiries into this or any other information required to determine my suitability for
employment. I also understand that if employed, any false statements on this application can be considered sufficient reason for
dismissal.
Applicant’s Signature Date
PRE-EMPLOYMENT HEALTH SCREENING:
Pre-employment vaccination with Hepatitis B vaccine and a Tetanus booster are the employee’s responsibility and are
recommended. Annual influenza immunization will be provided as well as baseline tuberculin testing.
We thank all applicants for their interest, however, only those selected for interviews will be contacted.
Applications will remain active for three (3) months upon receipt.
Revised June 2009
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signature
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