First Name:
Middle Name:
Last Name:
Address:
City:
Province:	Postal Code:
Work Phone:
Home Phone:
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Date Available:
Position Applied For:	Direct Care Office Supervisory
Community Living Brant needs people for days, afternoons, evenings, nights, weekends, early mornings, and short notice call ins.  Please indicate if you are not able to work any of these shifts.
Are you able to work around cigarette smoke? yes no
Outline your experience with individuals with a developmental disability.
How have you assisted individuals to develop decision-making skills and exercise choices?
How have you assisted individuals to achieve their goals?
How have you assisted individuals to participate in their community?
How have you worked with others as a team player?
Have you had a job that required shift work? If so, please give details.
Work History
Name and Address of last employer From (mo/yr) To (mo/yr) Job duties / responsibilities Reason for leaving
Name and Address of second last employer From (mo/yr) To (mo/yr) Job duties / responsibilities Reason for leaving
Name and Address of third last employer From (mo/yr) To (mo/yr) Job duties / responsibilities Reason for leaving
Education
Institution Name No. Months / Yrs. Completed Program / Degree / Diploma / Certificate High School College University Other
Past Attendance
Company No. Days Absent Reason for Absence This Year Last Year Two Yrs. Ago
Do you have anything you would like to add?
All offers of employment are pending successful criminal reference check, and verification of education and valid Ontario drivers license.