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MAXSYS APPLICATION FORM (B-1A) (PLEASE PRINT) Full-Time Days

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Country of origin: CANADA
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FOR OFFICE USE ONLY:
APPLICATION FORM (B-1A) (PLEASE PRINT)
First/ Given Name
La
st/ Surname
Str
eet Address
City Province
Ho
me Phone Cell Phone
Em
ail Address
MAXSYS
Middle Initial
Ap
t/Unit
Postal Code
Oth
er Phone
Do you consent to receiving
electronic messages
? □ Yes □ No
Employee #:
Payroll Code:
Date Entered: _________________
Position Desired:
Employment Desired:
□ Temp □ Casual
□ Temp to Perm □ Summer Only
□ Perm Only □ Evening
□ Full-Time □ Days
□ Part-Time □ Weekend
□ Other ____________________
Date Available Hours Available
Are you legally entitled to work in Canada? Work Permit Number & Expiry Date (MM/DD/YY)
□ Yes □ No
Emergency Contact (Name & Phone Number) Desired Pay Rate
SI
N #* Date of Birth (MM/DD/YY)* Transportation
□ Car □ Public Transit □ Other
Have you ever been convicted of a criminal offense for which you have not been pardoned?
□ Yes □ No
EDUCATION
Level Completed? Institution Name & Location Diploma/ Degree Received
High School
□ Yes □ No
Trade School/ College
□ Yes □ No
Designations/ Certifications
Additional Education or Courses
LANGUAGES
English
□ Fluent □ Functional □ Basic
French
□ Fluent □ Functional □ Basic
Other Fluent Languages
□ German □ Italian □ Japanese □ Spanish
□ Korean □ Polish □ Portuguese □ Sign Language
□ Russian □ Vietnamese □ Other ____________________
EMPLOYEE AUTHORIZATION
I hereby certify that the information provided is true and accurate representation of the facts. I further give approval for
MaxSys to contact third parties to verify the data on this form or information gathered during an interview.
*Optional Fields
Signature Date
Page 1 of 9
B-1AF Version 1.0 Jan 2019
APPLICATION FORM (CONTINUED)
SECURITY CLEARANCE
Do you have security clearance?
□ Yes □ No (If No, please move to next section)
If yes, what level is your security clearance?
□ Enhanced □ Secret □ NATO Secret □ Top Secret
File Number Expiry Date (MM/DD/YY) Issued By
SOURCE
How did you hear about MaxSys? (Please check only one)
□ HRSDC Job Bank □ Working.com □ MaxSys Website
□ Yellow Pages □ Referral □ Walk-In
□ Radio □ Fax □ Personal Contact
□ Print Advertisement □ Email - Unsolicited □ Other ____________________
EMPLOYMENT AND REFERENCES (PLEASE PROVIDE A MINIMUM OF 2 REFERENCES BEGINNING WITH THE MOST RECENT)
Employer Dates (From - To)
Position Type of Business
Supervisor Contact Number
Rate of Pay Reason for Leaving
E
mployer Dates (From - To)
Position Type of Business
Supervisor Contact Number
Rate of Pay Reason for Leaving
E
mployer Dates (From - To)
Position Type of Business
Supervisor Contact Number
Rate of Pay Reason for Leaving
Page 2 of 9
SKILLS INVENTORY
Please check only those skills which you have working experience
FOOD SERVICE
□ Cook
□ Chef
□ Bartender - Smart Serve
□ Bus Person
□ Dish Washer
□ Banquet Server
□ Tray Preparation
OFFICE ADMINISTRATION
Typing WPM: ________
GENERAL LABOUR
□ Assembly Line
□ Bricklaying
□ Carpentry
□ Construction
□ Driver - Class ______
□ Electrician
□ Forklift Operator
□ Hammering
□ Janitorial
□ Landscaping
□ Inventory Management
□ Heavy Equipment Operation
□ Maintenance Repair
□ Manufacturing
□ Painting
□ Picker/ Packer
□ Plastic Mould Injection
□ Production Line
□ Soldering
□ Supervisor
□ Warehousing
□ Welding
□ Administrative Assistant
Do you have: Steel-toed footwear: Y / N Hardhat: Y / N
□ Data Entry Clerk
□ Desktop/ Graphics
□ Dictaphone
□ Executive Assistant
□ File Clerk
□ Legal Assistant
□ Mailroom
□ Medical Assistant
□ Office Clerk
□ Reception
□ Secretary
□ Switchboard
□ Typist/ Word Pro
□ Shorthand
PROFESSIONAL
□ Engineer - Type __________________
□ Educator
□ Human Resources
□ Office Management
□ Property Management
□ Translation
FINANCE/ACCOUNTING
□ Bank Clerk
□ Financial Analyst
□ Mutual Funds
□ Accounts Payable
□ Accounts Receivable
□ Accounting Clerk
□ Bookkeeping
□ Collections
□ General Accounting
□ Invoicing
□ Payroll
SALES/ MARKETING
□ Cashier
□ Demonstrator
□ General - Sales Rep
□ Host/ Hostess
□ Marketing - Advertising
□ Marketing - Direct Mail
□ Sales Representative
□ Sales Management
□ Retail Sales
CALL CENTRE
□ Bilingual CSR
□ CSR
□ Manager
□ Sales - Inbound
□ Sales - Outbound
□ Team Leader
□ Tech Support
SOFTWARE
□ Windows
□ Simply Accounting
□ AutoCAD
□ Corel
□ Illustrator
□ Internet
□ Lotus Notes
□ Lotus 123
□ Microsoft Access
□ Microsoft Excel
□ Microsoft PowerPoint
□ Microsoft Word
□ Microsoft Outlook
□ PeopleSoft
Page 3 of 9
TERMS OF EMPLOYMENT - PAGE 1
If hired by MaxSys, the Employee agrees to the following:
General:
MaxSys operates a business providing temporary workers to its Clients. MaxSys is not acting as an employment
agency or as the Employee’s agent to secure permanent employment with its Clients. The Employee shall, on all work
assignments, remain a MaxSys employee until an alternative agreement with a Client is reached. Employment with MaxSys will
likely comprise a variety of temporary work assignments with Clients. The temporary work assignments will comprise of a
variety of tasks and duties. The Employee’s employment is subject to the availability of work assignments calling for the
skills/qualifications possessed by the Employee, as determined by MaxSys in its absolute and sole discretion. The pay
rate is accompanied by vacation pay at the applicable minimum rate required by applicable employment standards legislation,
you agree and authorize MaxSys to issue your vacation funds each week with your weekly pay while on assignment.
Confidential Information:
All information whether in print, electronic or otherwise, that is used in the course of MaxSys
business is MaxSys confidential information which the Employee shall not use or disclose without MaxSys express written
consent. All information, whether in print, electronic or otherwise, that is used in the course of the Clients’ business is the
Client’s confidential information which the Employee shall not use or disclose without the Client’s express written consent. The
Employee agrees that the use of MaxSys confidential information to benefit, establish, or assist a similar business to that of
MaxSys will cause irreparable harm and damage to MaxSys. The Employee agrees that the prohibition on the disclosure and use
of MaxSys and Client confidential information continues beyond the termination of the Employee’s employment for whatever
reason.
Employee’s Information:
The Employee’s employment is conditional on the Employee providing all information lawfully
requested by MaxSys. MaxSys may provide the Employee’s personal information to Clients, e.g., information in the application
for employment or information concerning work, habits, character, skill and performance. The Employee must update his/her
address by January 31st every year for T4 purposes.
Employee Shall Not Leave Shift Early: The Employee shall work all hours required in each shift of a work assignment unless the
Employee has an excuse that is acceptable to MaxSys at its sole and absolute discretion. The Employee will not be paid for a shift
if he/she leaves the work assignment before the end of the shift unless the Employee has an excuse that is acceptable to MaxSys at
is absolute and sole discretion.
Just Cause for Termination: The Employee agrees that MaxSys has just cause for terminating the Employee’s Employment if:
(i)
T
he Employee provides false or misleading information to MaxSys prior to or during the Employee’s employment. (ii) The
Employee discloses or uses MaxSys or Client confidential information. (iii) The Employee does not comply with the terms of this
Agreement or any MaxSys policies. (iv) The Employee does not comply with the Client’s policies, procedures, or
Instructions. (v) The Employee’s actions or inactions constitute just cause at law.
Minimum Requirements of Applicable Employment Standards Legislation Governs Employee’s Employment:
The
Employee agrees that the minimum requirements of applicable employment standards legislation governs his/her employment
and meeting such minimum requirements satisfies all MaxSys statutory and common law obligations, including but not limited
to
vacation, leaves of absence and entitlement to notice (or payment in lieu) upon termination of employment. For greater
certainty and without limiting the generality of the foregoing, the Employee agrees that upon termination of employment in the
absence of just cause he/she will under no circumstances be entitled to notice (or pay in lieu) or compensation greater than the
minimum requirements contained in the applicable employment standards legislation.
Your Responsibilities: You acknowledge and agree that if you are unavailable for an assignment you must contact us immediately
and on a weekly basis (Friday) to advise of your status. If you have not contacted us (by email and phone) or if you are unavailable,
you will be deemed to have abandoned your employment and you will not be entitled to any notice of termination, nor pay in lieu
of such notice, and severance pay pursuant to contract, statute and the common law.
Availability: You acknowledge and agree that in the event you have not been assigned to perform work for a client for one week,
you are required to contact the agency (by email and phone) to advise them of your prolonged period of non-assignment. You
acknowledge and agree that if you fail to contact the agency at the beginning of each week (Monday), to confirm your availability,
you will be deemed to have been unavailable for work for that week.
Status: MaxSys is a staffing service offering temporary employment assignments. You agree that while on assignment with
MaxSys, you shall present yourself to the client as an employee of MaxSys.
Page 4 of 9
TERMS OF EMPLOYMENT – PAGE 2
Occupational Health and Safety: The Employee agrees to comply with all applicable occupational health and safety legislation
and regulations. The Employee acknowledges and understands that because of the location of work-sites, Training and
instruction on tasks and duties (and associated safety risks) that are unique to the Client’s workplace, are conducted at the
client work site. It is the employee’s right and obligation to refuse work or perform any task or duty for which he/she has not
received appropriate safety training, information, instruction, and supervision.
Termination: MaxSys may terminate this employment agreement and your employment at any time without cause, without
notice and without payment of compensation. You must provide 10 days written notice of your intention to terminate this
agreement. You agree that in the event you should terminate this agreement without the specified notice, MaxSys will incur
additional costs and damages. You hereby authorize MaxSys to deduct all amounts for damages or additional costs from any
amounts owed to you by MaxSys. You acknowledge and agree that for any payments forthcoming, MaxSys shall only be
required to provide the minimum, under provincial employment standards legislation.
You Acknowledge and agree that MaxSys will provide notice on a weekly basis to you. Upon completion of the project, you
acknowledge and agree that you are no-longer an employee of MaxSys and that your employment has automatically
terminated.
Performance:
The employee agrees that his/her employment may be terminated, at any time, without either notice
or termination pay in lieu of such notice, if: (a) the employee wilfully breaches any of his/her duties; or (b) the employee
engages in wilful misconduct, disobedience or wilful neglect of duty while on assignment working for a client of the
agency. You acknowledge and agree that you will have no action, cause of action, claim or demand against MaxSys or any
other person as a consequence of such termination.
Dispute Resolution:
Save and except matters of non-competition and non-solicitation, any dispute, controversy or claim
arising out of or in connection with this Agreement, or the breach, termination or invalidity thereof, shall be settled by way of
mediation to be conducted within 30 days of formal written notice by a party. In the event mediation is unsuccessful,
the parties will proceed to arbitration in accordance with the
Canadian Arbitration Rules.
The parties shall each bear
their respective costs. The place of arbitration shall be Ottawa, Ontario.
Fairness and Reasonableness:
You and MaxSys confirm that the provisions contained in the above paragraphs are fair and
reasonable and agree that upon any termination of this agreement by MaxSys, you will have no action, cause of action, claim or
demand against MaxSys or any other person as a consequence of such termination.
Return of Property:
Upon any termination of your employment, you will at once deliver to MaxSys, or the client, all
documents, effects, money or other property belonging to the client for which MaxSys is liable to others which are in
your possession, charge, control or custody.
Deductions:
All payments under this employment agreement will be subject to all appropriate statutory deductions.
Copy of Agreement:
You acknowledge receipt of a copy of this agreement signed by MaxSys.
Entire Agreement:
The terms set out in this Agreement, MaxSys policies (which may be amended by MaxSys at its sole and
absolute discretion from time to time), and the Employee’s application form constitutes the entire agreement between MaxSys
and the Employee. If any of these terms are deemed to be void, invalid or unenforceable, it shall not affect or impair the validity
or enforceability of any other term, and shall be treated as severable from the remainder of the agreement.
I acknowledge that I have read, understand and agree to the above terms and agree that my employment with MaxSys will
be governed by the above:
E
mployee Signature Date MaxSys (Employer) Signature
Page 5 of 9
WHMIS / OCCUPATIONAL HEALTH & SAFETY
ORIENTATION QUIZ
1. WHMIS supplier labels:
a. Act to warn workers about the hazards of the material
b. Should be easy to read and durable
c
. Must be in both English and French
d. All of the above
2. What does SDS stand for? ___________________________________________________________________ .
3
. Where should SDSs be stored at your worksite?
a. In or near your work area
b. T
he Boss’s office
c. L
ocked up in a file cabinet
4
. What are considered controlled products under WHMIS regulations?
a. F
ire extinguishers, gasoline, ammonia
b. Cosmetic devices, drugs, food
c. T
obacco, wood, manufactured articles
5
. What do these symbols stand for? (Fill in the blanks)
a) _____________________ b) _____________________ c) ____________________ d) _____________________
6. WHMIS workplace labels are required when:
a. T
he product is poured from its original container into a new one
b. When a bulk shipment arrives without a supplier label
c
.
I
f a material is produced on site
d.
A
ll of the above
7. Choose the three key elements in WHMIS:
a
.
E
ducation, personal protection, labelling
b.
E
ducation, substance identification, labelling
c.
E
ducation, SDS, labelling
d.
Education, SDS, personal protection
8
. What should be done if a hazardous chemical comes in contact with your skin?
a. I
mmediately refer to the supplier label and SDS and follow the first aid measures
b. C
all 911
c. D
o nothing
9. MaxSys has set a goal of ________ Lost Time Accidents?
Page 6 of 9
W
HMIS / OCCUPATIONAL HEALTH & SAFETY
ORIENTATION QUIZ (CONTINUED)
10. Disciplinary action consists of what consequence.
a. Verbal Warning
b. Written Warning
c. Suspension or Termination
d. All of the above
1
1. Employees are responsible for their cooperation in all aspects of the Health & Safety and for continually practicing
safety while performing their duties for our Clients. Employees must comply at all times with the Clients Health & Safety
Program and all Provincial Acts and Regulation.
a) True; b) False
12. Consuming alcohol or illegal drugs during working hours or breaks is prohibited. Employees who are taking over the
counter or prescription drugs that could affect their ability to perform their duties are to notify Client in confidence.
a) True; b) False
13. Personal Protective Equipment (PPE) as required by the Occupational Health & Safety Act and Regulations must be
considered a condition of employment with the Client and will be worn as required without exception.
a) True; b) False
14. If you are involved in a workplace accident, you must inform your MaxSys Representative immediately, so that they
can fulfill their Employer responsibilities.
a) True; b) False
15. The Occupational Health & Safety Act outlines three basic rights for all employees. They are:
1) The right to ____________________________________
2
) The right to ____________________________________
3
) The right to ____________________________________
1
7. What do you do if you are asked to perform a task or duty for which you have not received adequate occupational
health and safety training, information, instruction, and supervision?
a) R
equest safety training and do not perform until you received training, information, instruction, and supervision.
b) P
erform the task anyway because you believe you will figure out how to perform it in a safe manner on your
own.
OR
IENTATION STATEMENT
I
hereby acknowledge that I have received and understand the MaxSys general WHMIS information. I further
acknowledge that it is my responsibility to adhere to all of the MaxSys and its customers’ specific worksite safety rules
and procedures related to hazardous materials while on work assignments. I understand that any failure on my part to
comply with said rules and procedures could potentially result in disciplinary action removal from the assignment or
discharge.
E
mployee Signature: _______________________________________________ Date: __________________________________________
OFFICE USE: Quiz Grade: /21 MaxSys Representative Initials: ___________
Page 7 of 9
Choose the correct answers to question 15 from the
following word list:
Know, work, participate, walk, weekly, refuse, stop
E
MPLOYEE RESPONSIBILITIES
1. If for any reason you are to be late, sick or unable to report to your assignment you must call MaxSys immediately.
Leave a message if you have to call after hours.
2. When sent to a job that requires steel-toed boots, you must wear them to every shift.
3. Any injuries, accidents or near misses are to be reported to MaxSys as soon as they occur and no later than eight
(8) Hours later.
4
. Y
ou must report any work assignment which you have reasonable grounds for believing is likely to be unsafe and
refuse to perform all unsafe work until the safety issues are satisfactorily addressed in accordance with applicabl
e
o
ccupational health and safety legislation.
5. You must receive sufficient occupational health and safety training, information, instruction, and supervision with
respect to the performance of all tasks.
6. You should never perform a task for which you have not received adequate safety training.
7. If you are unsatisfied with an assignment please provide adequate notice for a replacement and we will make ever
y
effort to reassign you.
8. If an assignment is given over the phone, be sure to write all the information down accurately.
9. Do not accept an assignment if you are not able to complete the terms of the assignment.
10. If you are sick for more than 3 consecutive days you must provide MaxSys a medical certificate.
11. If company property (i.e. security passes, parking passes, safety vests, etc) is provided to you, these items are to
be
r
eturned to MaxSys upon completion of employment. Property that is not returned upon completion of
employment is subject to charge on a per item basis.
REPORTING HOURS
1. All hours must be reported to MaxSys every Friday by end of the business day. Any hours worked on Saturday or
Sunday must be reported by 10am Monday morning. Phone messages are accepted but payment will
not be
released until signed confirmation is received.
2. Reporting your hours late will result in missed hours and payment will be made the following week without
exception.
3. Work slips are supplied for some assignments, be sure to have one for each week.
4. Time reported over the phone by an employee or client will require signed confirmation before payment can be `
released.
5. All employees will be paid every Friday based on hours reported for the previous week. The pay period
runs from Monday to Sunday.
By signing below, I understand and agree that I will comply with all rules, policies, and procedures outlined above.
I understand and agree that failure to comply will result in termination of employment for cause.
Employee Name (Please Print) Employee Signature
Page 8 of 9
N
EW EMPLOYEE SAFETY ORIENTATION
By checking the above boxes and signing below, I confirm that I have reviewed the MaxSys New Employee Safety
Orientation and I understand all rules, policies, and procedures that apply.
Occupational Health & Safety Policy
☐
Alcohol & Drug Use Policy
☐
Employee Responsibility for Safety
☐
Employee Rights
☐
Work Refusal Process
☐
General Rules & Discipline
☐
Personal Protective Equipment
☐
Identifying & Reporting Hazards
☐
Anti-Harassment Policy
☐
Return to Work Program
☐
Safe Work Practices & Job Procedures
☐
Sprains and Strains
☐
Reporting Incidents
☐
Safety Training
☐
Semi Annual Safety Communication Meetings
☐
Workplace Hazardous Materials Information System (WHMIS) ☐
Safety Data Sheets (SDSs) ☐
Employee Signature: _____________________ Date: ______________________
Page 9 of 9
FOR OFFICE USE ONLY
Notes:
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MAXSYS APPLICATION FORM (B-1A) (PLEASE PRINT) Full-Time Days

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Completed 22 March 2021

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