South Shore Regional

Centre for Education

Janitor Application Form

Competition #:

Once completed, please submit to our office by utilizing one of the following: Fax: 902-***-**** - Mail: 69 Wentzell Dr., Bridgewater, NS B4V 0A2 Email: adcxkv@r.postjobfree.com Personal Information (please print)

Last Name First Name(s)

Address

Town/City

Province Postal Code Phone No. (Home) Phone No. (Cell) Email Address When would you be available to start? Were you previously employed with the Regional Centre? Yes No Education and Training

Education and Training

Certificate/Diploma/Degree

Received?

Name of

Certificate/Diploma/Degree

Received

Name and Location of

Educational Institution

High School

Yes

No

Community College, Business

School, Technical School, etc.

Yes

No

University

Yes

No

Skills and Abilities

First Aid Level Expiry Date

CPR Level Expiry Date

WHMIS Completion Date

Driver’s License Class Endorsements

Other

Other

Employment History (Start with your current or most recent employer) Employer Supervisor’s Name

Start Date (YY/MM/DD) End Date (YY/MM/DD) Position Responsibilities

Reason for Leaving

Employer Supervisor’s Name

Start Date (YY/MM/DD) End Date (YY/MM/DD) Position Responsibilities

Reason for Leaving

Employer Supervisor’s Name

Start Date (YY/MM/DD) End Date (YY/MM/DD) Position Responsibilities

Reason for Leaving

References

(One of your references must be your current or most recent immediate supervisor. A total of 3 references is required) Name Relationship Work Place Phone Number

Applicant’s Declaration

I certify that all statements in this application are true. Signature Date (YY/MM/DD)