Kahak Health Care

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.:: Employment Application ::.

BASIC INFORMATION
First name	Marital Status	Married Single
Last name	Date of Birth
Address	Social Security #
City	Phone Number
Province	Email Address
Postal Code	Classidifation
Licence number

EDUCATION : list nursing scool and/or college

Name & Location of School	Month & Year of Graduation	D=Degree C=Certificate & Date Issued

WORK REFERENCES: List below starting with your current or latest employer. These references must relate to the position for which you are applying.
Name of facility	Location	Phone Number	Dates Employed	Reason for leaving or presently working



CPR Certification Date

Do you have any experience in any of the following areas? Date's (Years) & where you had the experience . Note: These experience's must correspond to your experience under*present Licensure. Please also include types of experience, and comfort level of experience.
Neo-Natal	IV	Pediatric
Home Care	Ventilator	Nursing Home
Med/Surg	Cath/Foley	Trach Care
Hospitals	Hospice	CCU
Rehabilitation	ICU	Well Baby
ER	CLSC	Live-In
Feeding Tubes : Pediatric		Adult

AVAILABILITY

Days Evenings Nights Anytime
Weekends Weekdays

  1      Date :        Shift :      AM         PM         ND
  2      Date :        Shift :      AM         PM         ND
  3      Date :        Shift :      AM         PM         ND
  4      Date :        Shift :      AM         PM         ND
  5      Date :        Shift :      AM         PM         ND
  6      Date :        Shift :      AM         PM         ND
  7      Date :        Shift :      AM         PM         ND
  8      Date :        Shift :      AM         PM         ND
  9      Date :        Shift :      AM         PM         ND
  10    Date :        Shift :      AM         PM         ND
  11    Date :        Shift :      AM         PM         ND
  12    Date :        Shift :      AM         PM         ND
  13    Date :        Shift :      AM         PM         ND
  14    Date :        Shift :      AM         PM         ND

We may contact the employers listed above unless you indicate
those you DO NOT want us to contact:

US CITIZEN Yes No IF not, resident card #

LANGUAGE ABILITY : Please indicate if you can speak any foreign languages .

English French Yes, i do speak a foreign language :

EMERGENCY CONTACT

Name Address Phone
Do you work another job? Yes No Can we call you there Yes No if Yes, please complete :

Company		Phone #
Days		Floor
Hours		Availabitity

Have you ever been convicted of a crime? Yes No

I certify that I am not addicted to any depressants, stimulants, narcotics, drugs, alcohol, or other substances that may alter my behavior. Any falsification will be sufficient grounds for my release from employment. I have been informed by Kahak Health Care that random drug screens will be performed.

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed; falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

Under no circumstances, without the prior written consent of Kahak Health Care, LLC may I to be employed directly or indirectly for any client or member of the family of any client for whom I have cared for as an employee of Kahak Health Care

By clicking Submit you are certifying that all of the above information is correct and complete: