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Our Mission Statement:
To be a collaborative and innovative team committed to providing quality health programs and services to our community

Hanover & District Hospital,
90-7th Avenue, Hanover,
Ontario Canada, N4N 1N1
Tel: 519-364-2340
Fax: 519-364-6602

Email: webmaster@
hanoverhospital.on.ca

Visiting Hours:
2:00 pm - 8:00 pm

Parking:
$3.00 per vehicle
Monthly and annual parking passes available

:: Driving Directions & Map

Application for Employment

90-7th Ave. Hanover, ON N4N 1N1
Ph: 519-364-2340
This application has been reviewed by the Ontario Human Rights Commission

Please fill out the form below and we will contact you via email or phone.
Fields marked with an asterisk (*) must be filled out.

Type of Position Desired

First Choice:*

Second Choice:*

Date Available:*

Salary Desired:*

Type of Employment Desired:*

FULL TIME PART TIME STUDENT TEMPORARY SUMMER

If application, are you available to work all shifts?* YES NO

Weekends?* YES NO

Personal Information:

Last Name:*

First Name:*

Email:*

Address (Street & Number):*

City:*

Postal Code:*

Home Telephone:*

Business Telephone:*

Are you between 18 and 65 years of age?*

YES NO

Are you legally entitled to work in Canada?*

YES NO

Are you a previous employee?*

YES NO

Date employed:

From

Department:

Reason for leaving:

Education:* Please indicate highest grade completed 8 or below 9 10 11 12 13

Nature of Course:* Academic Commercial Vocational Other

Post Secondary Education *

Education Level	Courses of Study	Length of Course	List Degree, Diploma or Grade completed(Ontario Equivalent)
University
College or Technical
School of Nursing
Other

Please list any additional courses, skills, language skills, interests, hobbies, special qualications or other experience which you feel are relevant to the position(s) for which you are applying.

Office Skills:
Typing:

Word Processing:

Dictaphone:

Data Entry:

Medical Terminology:

Other(Describe):

Professional and Technical Graduates:

Are you registered in Ontario?

YES NO

Renewal Date:

If not registered, date exams were written

Ontario Registration Number

R.N.

R.P.N.

Other:

Employment History* - Please enter your present or most recent place of employment first and continue in sequence

1	Employer*	Position*	Describe duties and responsibilities - Indicate department and/or clinical area(where applicable) *
	Immediate Supervisor*	Dates: From* To*
	Address*	Reason for Leaving *
	Telephone*	Final Salary *

2	Employer	Position	Describe duties and responsibilities - Indicate department and/or clinical area(where applicable)
	Immediate Supervisor	Dates: From To
	Address	Reason for Leaving
	Telephone	Final Salary

3	Employer	Position	Describe duties and responsibilities - Indicate department and/or clinical area(where applicable)
	Immediate Supervisor	Dates: From To
	Address	Reason for Leaving
	Telephone	Final Salary

4	Employer	Position	Describe duties and responsibilities - Indicate department and/or clinical area(where applicable)
	Immediate Supervisor	Dates: From To
	Address	Reason for Leaving
	Telephone	Final Salary

May we contact your present and previous employers?* YES NO

References: Business (Not Relatives)*

1	Name*
	Position*
	Employer *
	Telephone Number *
2	Name
	Position
	Employer
	Telephone Number
3	Name
	Position
	Employer
	Telephone Number
4	Name
	Position
	Employer
	Telephone Number

Please Read Carefully*

I understand that any misrepresentation made by me in connection with this application may be just and sufficient cause for separation from Hanover and District Hospital.

I understand that my appointment is conditional upon successful completions of a probationary period.

I understand that the completion of a health review is required for all new staff members.

I agree to have union dues deducted from my wages, if my position requires it.

If I am employed in a department requiring shift work, I agree to work all tours of duty as requried.

I agree with the above statements.

I do not agree with the above statements.

Date: