Nurses Application

First Name

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Last Name

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Address

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City

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Province

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Postal Code*

Country

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Home Phone # (555-555-5555)

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Cell #

E-mail Address

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Re-type e-mail address

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Main intersection closest to your home.

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Where are you willing to work?

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Downtown Toronto East York Scarborough North York York Region Durham Region Etobicoke Chatham-Kent Sarnia-Lambton

A person legally eligible to work in Canada is a Canadian citizen, a landed immigrant, permanent resident or a holder of a valid work permit.

Are you legally eligible to work in Canada?

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Yes No

Have you ever been convicted of a criminal offence for which you have not been pardoned?

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Yes No

Designation

Registered Nurse Registered Practical Nurse

Do you have a current unrestricted Ontario Certificate of Registration

Yes No

Do you have a current Basic Cardiac Life Support (BCLS) Certificate

Yes No

Please select all the area(s) you are competent to practice in:

Palliative Care Pediatrics Wound Care I. V. Therapy Foot Care Mental Health Dialysis Diabetes Chemotherapy Central Line Pumps Vent Trach Other

Other

Please select the Nursing program(s) you are interested in

Shift Visiting

Please select the client group(s) you are interested in working with

Adults Child & Family

All visiting Nurse positions require access to a car, valid driver's license and car insurance.

Do you have access to a car?

Yes No

Do you have a valid driver's license and car insurance?

Yes No

AVAILABILITY

If you are interested in Shift Nursing, ideally how many hours per week would you like to work?

If you are interested in Visiting Nursing, ideally how many visits per week would you like to work?

When are you available to start?