GASHA: External Job Application Form

1. Identification:
*First Name:
*Middle Name:
*Last Name:
*Street Address:
*Town/City:
*Province:
*Postal Code:
*Home Phone #:
Work Phone #:
Mobile Phone #:
Email:

2. *Were you previously employed by the Guysborough Antigonish Strait Health Authority?
No	Yes
When?
Position:

Upload Coverletter: [optional]

Upload Resume: [optional]

3. To be completed by Nursing/Technical Applicants Only

Are you registered with your Professional Association for the current year? Yes No

Registration #:

In what clinical areas are you most interested?

If you have your resume attached, please click here to skip the section 4 and 5. In the absence of a resume, please complete the following section 4 and 5.
4. Education
A. Education Level: High School
Name of School or Institution:
Number of Years Attended:
From:	To:
Graduate: Yes No
Degree or Diploma:

B. Education Level: Vocational/Business or Nursing School
Name of School or Institution:
Number of Years Attended:
From:	To:
Graduate: Yes No
Degree or Diploma:

C. Education Level: University
Name of School or Institution:
Number of Years Attended:
From:	To:
Graduate: Yes No
Degree or Diploma:

D. Education Level: Other
Name of School or Institution:
Number of Years Attended:
From:	To:
Graduate: Yes No
Degree or Diploma:

5. Employment History/Professional Experience (begin with present or most recent)
A. Employment History 1
Name and Address of Employer:
Supervisor Name and Title:
Position Held:
From:	To:
Reason For Leaving:
B. Employment History 2
Name and Address of Employer:
Supervisor Name and Title:
Position Held:
From:	To:
Reason For Leaving:
C. Employment History 3
Name and Address of Employer:
Supervisor Name and Title:
Position Held:
From:	To:
Reason For Leaving:
D. Employment History 4
Name and Address of Employer:
Supervisor Name and Title:
Position Held:
From:	To:
Reason For Leaving:

*6. To be Completed by All Applicants

I certify that all statements on this application are true and complete to the best of my knowledge, and I hereby authorize the Guysborough Antigonish Strait Health Authority to make any inquiries to determine my suitability for employment. I understand false and/or incomplete statements shall be sufficient cause for disqualification or dismissal.

Agree

Disagree

Date: