Steripro Canada

STERIPRO CANADA Employment Application

APPLICANT INFORMATION

Last Name Middle Initial Date

Street Address Apartment/Unit #

City Postal Code

Phone Salary Date Available Expectations Position Applied for

Are you legally entitled to work in Canada? YES

Have you ever worked for this company? YES If so, when?

Have you ever been convicted of a criminal YES If yes, explain offence which you have not been pardon? Do you have a relative currently employed by SteriPro? YES NO If yes, which department? EDUCATION

High School Did you From To YES NO Diploma graduate College/ University Did you From To YES NO Degree graduate Other Did you From To YES NO Degree graduate

PREVIOUS EMPLOYMENT

Company Phone ( )

Address Supervisor

Job Title Starting Salary $ Ending Salary $

Responsibilities

From To Reason for Leaving

May we contact your previous supervisor for a reference? YES NO

Company Phone ( )

Address Supervisor

Responsibilities

May we contact your previous supervisor for a reference? YES NO

SteriPro Canada Employment Application-09/2011 revised Company Phone ( )

Address Supervisor

Responsibilities

May we contact your previous supervisor for a reference? YES NO REFERENCES Please list three professional references.

Full Name Relationship

Company Phone ( )

Address

Company Phone ( )

Address

Company Phone ( )

Address

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature Date

SteriPro Canada Employment Application-09/2011 revised