Please complete all blanks with the required information. Resumes may accompany completed applications.
Additional pages may be attached to complete the required information.

First Name: Middle Initial: Surname:

Residence Telephone #: () - Cellular Telephone #: () -


City: Province: Postal Code (no spaces):

Email Address:

1. Are you legally entitled to work in Canada? YES NO
2. Are you willing and able to work shift work?
(which may include weekends, night shifts and holidays)
If No, when would you not be able to work?


3. Position applied for:

How did you hear about this position:

EMPLOYMENT HISTORY (fill out if you do not have a résumé):

4. Please list in date order, starting with your current or most recent position, all previous employers for the past 3 years, or since you left school.

Employer's Name: Name of Supervisor:
Dates of Employment — From / To /
Position Held:
Main Duties:
Reason for Leaving:

Employer's Name: Name of Supervisor:
Dates of Employment — From / To /
Position Held:
Main Duties:
Reason for Leaving:

Employer's Name: Name of Supervisor:
Dates of Employment — From / To /
Position Held:
Main Duties:
Reason for Leaving:

5. Are you willing to cross a picket line? YES NO

6. Are you willing to work out of town or province if expenses paid? YES NO


7. Please indicate highest grade level completed:

  Please select highest grade level completed:    Diploma Obtained? YES NO

  If diploma was obtained, please specify:

  If you attended a Business or Trade School, please specify below:

8. List any special skills, attributes, certifications, or courses taken in addition to the above:


9. Please indicate any verbal or written language skills you may possess.

Languages Can Speak Fluently Conversational Only Write/Read Fluently

NOTE: The following questions are asked for the purpose of frank, confidential discussion at the time of an interview, in advance of routine inquiries, which are made as a matter of standard policy. An affirmative answer will not disqualify you from consideration of employment.

10. Have you ever been convicted of a criminal offense, in any Province, for which a pardon has not been granted?

If yes, when? /

I understand that, if accepted for temporary employment, I will be working for Patriot Source 1.

I understand I will be on the payroll of Patriot Source 1.

I understand I will be on site at Patriot Source 1.

I understand that the nature of the work with Patriot Source 1 is casual and that all placements are for the duration of the assignment only (if applicable). I further understand that I could be moved to various assignments with different pay rates.

I hereby declare that the foregoing information is true and complete to the best of my knowledge. I give Patriot Source 1 permission to verify my employment reference for work record for bonding purposes. I understand that a false statement my disqualify me from employment or cause my dismissal.

I recognize that possible employment with Patriot Source 1 may entitle me to information about clients and/or staff which should be treated as confidential. This information, including all reporting material information, will be considered Proprietary Information and will be held in strictest confidentiality.

Information obtained from present and/or former employers is to be considered as "Confidential and Privileged" and used only for purposes of assessing employment suitability in relation to current capabilities, including work skills, work habits and personal character.

By this authorization, Patriot Source 1 and all who may provide information as reference herein are released from any liability which may otherwise ensue.

Signature (enter your initials):    Date:

For Ontario Residents Only
Patriot Source 1 staffing service offering temporary assignments. Due to the nature of temporary employment, I understand that I will have complete discretion to elect to work or not to work when requested to do so, and that I may exercise this discretion without suffering any negative consequence of penalty.

I further understand that in having this right, I am exempt from Part X of the Ontario Employment Standards Act 2000 and that any calculation of Public Holiday Pay will be made in accordance with the policies of Patriot Source 1.

Signature (enter your initials):    Date: //

RESUME (copy and paste résumé in the box below):