Regional Health Authority of Central Manitoba Inc.

Name

Address

Phone

E-mail address

Are you legally entitled to work in Canada? Yes   No

Are you aware of any health or physical conditions that could affect performance on the job? Yes   No

Have you ever been employed by RHA Central or any of its affiliates?
If yes, please list facility/program and dates Yes   No

Position(s) Applied For

Date Available

Facilities/Program(s)

Describe any of your work related skills, experience or training that relate to the position being applied for.

Please indicate any languages other than English that you speak, read or write

List your last three employers beginning with the present/most recent

Please attach resume identifying skills, competencies and educational background.

The Regional Health Authority - Central Manitoba Inc. encourages Aboriginal people to self-identify by completing the voluntary self-declaration below.

I declare myself to be Aboriginal descent. First Nations Métis Inuit

I declare the foregoing information to be true and complete to the best of my knowledge and understand that any misrepresentation or material omission is grounds for refusal of employ me or, if I am employed, for dismissal with cause.

If employed I agree to abide by the polices, procedures and working conditions established and/or amended from time to time by the The Regional Health Authority - Central Manitoba Inc. I hereby authorize the The Regional Health Authority - Central Manitoba Inc. to conduct a personal investigation in connection with my application for employment including a Criminal Record Check and Child Abuse Registry Check. All costs associated with these checks will be my responsibility.

Yes   No

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