Employment Application Form
Instructions: Office Use Only

Please complete all sections as thoroughly as possible. If you are completing this on-line, please use Mozilla Firefox as it will allow you to save the form once you have filled out the fields. It is necessary to provide complete information as this will be used to determine eligibility and qualifications for a position. A separate application is required for each position/competition. Applications must be received at the appropriate closing location by the date indicated in the advertisement.

Candidates who are selected for a position will be required to complete a CPIC check upon offer of employment.

The personal information requested on this form is collected and managed as per applicable Privacy Legislation.

All information to us will be considered as supplied in confidence.

Once you have completed the application, you can either save it (using Mozilla Firefox) and email it as an attachment, or print it and mail it. Please also include with your completed application a resume and cover letter.

 Date Received:
Position Information




Indicate the type of employment you are requesting.
Personal Information








Canadian Citizen: Work Permit: Landed Immigrant: Permanent Resident: Other: If other, please specify:
Education & Training

Please describe secondary, post-secondary, courses and training which have given you work related knowledge and skills. Start with highest level achieved and specify the degrees, certificates or diplomas completed. Official documentation may be required. Attach a separate page if necessary.
Name of Institution or Organization Location Year Taken Area of Study / Course Grade / Certification / Diploma / Degree Completed
Yes No
Association / Professional Affiliations
Are you able to provide proof of academic qualifications?

List any active memberships or registrations in a professional or career related organization or society.
Work History
Have you previously been interviewed for a position or employed by Reconnect Mental Health Services? No Yes
If yes, please indicate location and dates:

Beginning with your most recent experience, describe your work history. You may wish to include relevant volunteer positions. In the area for "Duties and Skills" describe the major duties and skills acquired/used as they relate to the position you are applying for. If any references have known you by a previous name, please specify. Attach additional pages if required.
Employer and Location:
From (yyyy/mm/dd)
 To (yyyy/mm/dd)
Supervisor — Reference
Supervisor's Telephone No.
 Reason for Leaving
Position Held
 Regular Employment Volunteer
Student Placement 		Salary No. of People Supervised (if applicable):
Duties and Skills:
Employer and Location:
From (yyyy/mm/dd)
 To (yyyy/mm/dd)
Supervisor — Reference
Supervisor's Telephone No.
 Reason for Leaving
Position Held
 Regular Employment Volunteer
Student Placement 		Salary No. of People Supervised (if applicable):
Duties and Skills:
Employer and Location:
From (yyyy/mm/dd)
 To (yyyy/mm/dd)
Supervisor — Reference
Supervisor's Telephone No.
 Reason for Leaving
Position Held
 Regular Employment Volunteer
Student Placement 		Salary No. of People Supervised (if applicable):
Duties and Skills:
Skills / Experience
Check areas of skills/experience that you have which relate to the advertised position or, if this is a general application, to the position(s) that interests you, and attach any appropriate documentation.
No. of years / months experience / training List related skills that apply
Mental Health
Case Management
Addictions
ABI
Other

Skills / Achievements

Briefly summarize your knowledge and major skills / achievements which relate to the advertised position or, if this is a general application, to the position(s) that interests you. You may use this space to enter other information you would like us to consider in reviewing your application. Please use reverse side if necessary.

Driver's License Information
Currently have a valid driver's license for the province of Ontario? Yes No
List class(es) of valid driver's license you hold. List any restrictions / endorsement definitions on license. If required, do you have access to a vehicle? Yes No

Depending on the amount of travel incurred as a result of work you may be required to carry business coverage insurance.
References
Reference checks will be conducted to assess your past work performance and may include checks of attendance records. In addition to the references identified in the "Work History" section, you may wish to provide further references. If any references have known you by a previous name, please specify.
Name Telephone No. Relationship No. of Years Known

Applicant Signature

Please read carefully before authorizing. This application is not valid unless your name, as authorization, is signed or written in the "Signature" space provided below. (Note: If this application is submitted electronically, it is not valid unless your name is keyed in the "Signature" space provided below).

Your authorization on this application form is your consent that as a condition of being considered for employment at Reconnect Mental Health Services, references about past work performance will be obtained from your current and previous employers.

I certify that the information provided in this application or attachments / resume is true and complete. I understand that if any information in this application or attachments / resume is found to be untrue or incomplete, my application may be rejected or I may be terminated for just cause in the event that I am the successful applicant.

Date Signed yyyy/mm/dd
X
Signature (If applying electronically please type your name as authorization)

For Office Use Only

Hiring Notes: