CMHA Employment Application 2011

APPLICATION FOR EMPLOYMENT
(Please complete one application for each employment opportunity)
Position Applied for:
Please list any
add'l applications in
past 3 months:
Employment Preference:
Last Name: First Name:
Previous name used in Education/
Employment (if applicable):
Street Address: Postal Code:
City/Province: Telephone:
Are you presently employed with CMHA?
Are you legally authorized to work in Canada?
Have you worked previously for CMHA?
(if Yes,
give dates)
Are you related to anyone presently working for CMHA?
if Yes,
to whom?
How did you learn about this position?
if Other,
please specify?
Education (Please also attach resume)
NAME & LOCATION OF SCHOOL
YEARS
ATTENDED
DATE
GRADUATED
COMPLETED DEGREE, DIPLOMA or
CERTIFICATE (e.g. BA, DSW)
HIGH
SCHOOL
POST
SECONDARY
Professional Registration or Affiliation
CPR Certification (if Applicable)
First Aid Certification (if Applicable)
Active:
Active:
Active:
Expiry Date (YYYY-
MM-DD)
Alt Tel#:
Expiry Date (YYYY-
MM-DD)
Expiry Date (YYYY-
MM-DD)
No Yes
No Yes
No Yes
Email:
Print Form
(Select One)
Print Form Submit by Email
Employment History (Start with your most recent employment)
Organization Name &
Location:
Position:
Other:
FROM:
Dates of Employment
(YYYY-MM-DD):
Hours per
Week:
Supervisor
Name & Title:
Reasons for Leaving:
Organization Name &
Location:
Position:
Other:
Hours per
Week:
Supervisor
Name & Title:
Reasons for Leaving:
Organization Name &
Location:
Position:
Other:
Hours per
Week:
Supervisor
Name & Title:
Reasons for Leaving:
Organization Name &
Location:
Position:
Other:
Employment
Status:
Hours per
Week:
Supervisor
Name & Title:
Reasons for Leaving:
TO: FROM:
Dates of Employment
(YYYY-MM-DD):
TO: FROM:
Dates of Employment
(YYYY-MM-DD):
TO: FROM:
Dates of Employment
(YYYY-MM-DD):
Please Indicate your years of experience in a human services environment?
Please Indicate your years of experience working with individuals with a mental health concern?
Please Indicate your years of experience in supervising staff?
TO:
Check if Current
Employer
Employment
Status:
Hours per
Week:
Employment
Status:
Hours per
Week:
Employment
Status:
Updated: January 2011
(Select One)
(Select One)
(Select One)
(Select One)
Employment References
NAME TITLE/COMPANY RELATIONSHIP PHONE # EMAIL
Have you ever been convicted of a criminal offence for which a pardon has not been granted?
NAME
If Yes, Please Explain:
I authorize CMHA to obtain references from past and present employers (as indicated below) and I release
CMHA from liability or damages incurred as a result of any inquiry made and the furnishing of this information.
Your Present Employer Your Former Employers
I certify that the statements made by myself in this application are true, accurate and complete. I understand
and agree that a false statement made either in this application or during the course of my candidacy for
employment with CMHA may disqualify me from employment or result in dismissal.

I also understand that any personal information that I have disclosed during the course of my candidacy or in
my application for employment may be shared with members of the Hiring Committee, the CMHA HR
department or appropriate members of the CMHA management team at any time during the course of my
candidacy or thereafter, should I become employed by CMHA or not, for any reasonable employment
purposes.
Date:
Successful applicants will be required to provide proof of education credentials upon hire and
complete a criminal record check

We thank all applicants but only those under consideration will be contacted.
By completing this application form,
I agree to the terms as indicated above:.
No Yes
No Yes No Yes
No Yes
Updated: January 2011 PLEASE NOTE: This form must be completed in Adobe Reader or Professional in order to function properly
Submit by Email