KTHR External Application Form - Kelsey Trail Health Region

Application for
Employment
Please include a copy of your resume.
Kelsey Trail Health Region
Human Resources
Box 1480, Melfort, SK S0E 1A0
Telephone: (306) 752-7581
Fax: (306) 752-2276
Email: employment@kthr.sk.ca
Date Received by HR: _____________
PERSONAL INFORMATION (Please Print)
Name: _____________________________________________________________________________
Last Name First Name Middle Initial
Address: ________________________________________________ Email: _____________________
Number Street Town/City & Province/Postal Code
Home Phone: __________________
Alternate Phone: ___________________________________
Have you previously been employed in the healthcare sector in this region? Yes No
If yes, where? ________________________________When? _________________________
Are you presently employed? Yes No If yes, position held ______________________
Are you legally eligible to work in Canada? Yes No
Are you between the ages of 16 and 65? Yes No
Have you committed a criminal offence for which a pardon has not been granted? Yes No
Do you have a disability that will affect your ability to perform any of the functions of the work for
which you are applying? Yes No If “yes”, what function can you not perform and what
accommodations could be made which would allow you to do the work adequately?
___________________________________________________________________________________
___________________________________________________________________________________
POSITION/WORK DESIRED
Position Desired: ____________________________________________________________________
Date available to begin work: _________________Work site preferred, if any: _________________
Available for shift work: Yes No
If “yes”, please indicate: Days Nights Evenings Weekends
Will you accept: Full Time Part Time Temporary Casual
Area of service preferred, if any: 1. ________________2. _______________ 3. _______________

EDUCATION AND TRAINING
Type of Education
School Name
& Address
Highest Level
Completed
Grade/certificate/diploma/degree
Completed? (Yes or No)
Grade / High School
University
Business, technical,
trade or other training
Describe any additional skills, training or knowledge you have that you feel are related to the
position you wish to fill: ___________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
SPECIALIZED SKILLS
Clerical Skills: Keyboarding/Typing WPM_____ Dictaphone Medical Terminology
Computer Skills: Word Processing Spreadsheets
Computer Knowledge: (software programs you have used)______________________________
Technical/Trades/Maintenance/Other Skills___________________________________________
BLS Certification (CPR) Level_______________ Date of Last Course______________________
Language Skills: Spoken: ________________________ Written: __________________________
Other Skills: _______________________________________________________________
CERTIFICATION (for all certified professions)
Please indicate what profession you are qualified for (eg. Registered Nurse, Respiratory Therapist):
__________________________________________________________________________________
Are you currently registered to work in Saskatchewan? Yes No
If yes, Saskatchewan Registration # ______________________
If no, are you eligible to be registered in Saskatchewan? Yes No

EMPLOYMENT HISTORY
Please list current and previous employment beginning with most current. Attach additional
information if needed.
Organization Name: From: To:
Address and Phone #
Name of Supervisor:
Job Title:
Salary Received:
Brief Description of Job:
Reason for Leaving:
Organization Name: From: To:
Address and Phone #
Name of Supervisor:
Job Title:
Salary Received:
Brief Description of Job:
Reason for Leaving:
Organization Name: From: To:
Address and Phone #
Name of Supervisor:
Job Title:
Salary Received:
Brief Description of Job:
Reason for Leaving:
May we contact any or all of the supervisors/employers listed above? Yes No
If not, indicate which one(s) you do not wish us to contact: ______________________________
Do you require notice prior to our contact? Yes No

REFERRAL SOURCE
Newspaper Ad Career Fair Professional Publication Former Employee
Web Site School Events Post Secondary Recruiting Job Board
Employee Referral Name of employee who referred you: _________________________
Employee email address: _____________________ Employee Phone Number:__________
REFERENCES - Please do not include relatives
Name:
Address:
Occupation:
Phone:
Name:
Address:
Occupation:
Phone:
Name:
Address:
Occupation:
Phone:
VOLUNTARY SELF-DECLARATION (optional)
Kelsey Trail Health Region is working toward a workforce representative of the public it serves.
Please answer the following questions. Your answers will be kept confidential and will help to
improve the representation of Aboriginal peoples in Kelsey Trail Health Region.
Are you of Aboriginal Ancestry (Status Indian, Non-Status Indian, Metis, Inuit)? Yes No
If Yes, to which group do you belong?_______________________________________________
STATEMENT BY APPLICANT
1. I certify that the facts set forth in this employment application are complete and true.
If it is found that I have given false information in this application, such falsification will
constitute full and sufficient grounds for rejection of this application, or dismissal from
employment.
2. I give permission to Kelsey Trail Health Region to obtain information regarding my
previous employment or educational background.
Signature of applicant: ________________________________
Date: ____________________

THANK YOU!
Thank you for your interest in employment with the Kelsey Trail Health Region and for taking the
time to complete this application form. Your application will be kept on file for six (6) months; please
notify us of any change of address/phone number during that time.
Please return this form to:
Kelsey Trail Health Region - Human Resources
Box 1480, Melfort, SK S0E 1A0
Telephone: (306) 752-7581; Fax: (306) 752-2276
Email: employment@kthr.sk.ca
The Kelsey Trail Health Region is committed to providing a safe and healthy environment for employees, volunteers, clients and the
general public. This includes the prevention of harassment and violence and the promotion of a scent-free/reduced workplace.
Kelsey Trail Health Region is committed to a Representative Aboriginal Workforce.