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JOB APPLICATION FORM
Name
(Required)
First
Last
Address
(Required)
Street Address
City
Province
Postal Code
Date of Birth
(Required)
MM slash DD slash YYYY
Phone
(Required)
Email
Do you have a vehicle?
YES
NO
Have you worked for a temporary placement agency before?
YES
NO
What is your availability?
Full Time
Part Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Please indicate the YEARS OF EXPERIENCE you have in the following jobs (If NONE leave it BLANK):
Construction Labour
Form Stripping
Carpentry
Concrete / Cement
Drywall
Flagging
Heavy Equipment
Forklift
Safety Officer
Warehousing
Painting
Moving
Roofing
Landscaping
Cleaning
First Aid Attendant (+level)
Medical Questionnaire (CONFIDENTIAL)
We request basic medical information to help us find a work position and environment suitable to your capacity, thus minimizing the risk of serious injury to yourself, your colleagues, and/or everyone else involved.
Do you have a Heart Condition?
YES
NO
Do you have Epilepsy?
YES
NO
Do you have a history of Back Problems?
YES
NO
Do you have Diabetes?
YES
NO
Do you have High Blood Pressure?
YES
NO
Have you ever had an Eye Injury?
YES
NO
Are you Bondable?
YES
NO
Have you ever had and Major Joint Injuries?
YES
NO
Have you ever had a Head Injury?
YES
NO
Do you have a Hearing Problem?
YES
NO
Have you had any Previous Fractures?
YES
NO
Do you have any Allergies?*
YES
NO
Do you have a Hernia?
YES
NO
Do you have Dizzy Spells?
YES
NO
Are you currently taking any Medications?**
YES
NO
Are you Medically Cleared and Fit to Work with No Restrictions?
YES
NO
*If “YES” please indicate your allergies
**If “YES” please indicate what medications
Is there any present medical condition or other information we should be aware of including injuries or chronic ailments?
Please fill out an EMERGENCY CONTACT
(I authorize JPD Staffing Inc. to contact the following person(s) on my behalf in case of an emergency)
Name
First
Last
Phone
Name
First
Last
Phone
Dispatch Policy
I understand that if I wish to be eligible for dispatch work ("on-call" status) for a particular day, I will contact the JPD Staffing Inc. office and indicate my dispatch availability. If I cannot be contacted, I forfeit my "on-call" status position to the next available worker contracted. I understand that all work is on a casual basis and that I do not commence work until I have attended and started working at the location to which I have been dispatched. I also make clear my understanding that none of the above is a guarantee of work.
By submitting this form, I declare that all statements in this application are deemed accurate to the best of my knowledge. Any omission by myself or any misrepresentation is grounds for immediate dismissal. My employer can request an examination by a physician as required.
Get In Touch
Please fill out the contact form below to get in touch with us or call at 778 228 9181
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