Please complete the form below and click the submit button. Personal:   Mr.   Ms. First Name: Surname: Mailing Address: City: Province: Postal Code: Telephone: Email: Position Applying For: Please Select -------------------- Bartender Disc Jockey Runner Security Server Door/Coatcheck Kitchen Food Prep Office Assistant PAL's Market Attendant Education: School Attending: Please Select -------------------- Canadore College Nipissing University Enrolled Program: Current Year: Please Select -------------------- 1 2 3 4 5 Previous School Attended: Course Taken: Year Completed: Please Select -------------------- 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Employment: Company Name: Employed From: Select ------ 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Position: Address: Employed To: Select ------ 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Supervisor: Reason for leaving: Salary: May we contact this employer?: Yes:     No: Company Name: Employed From: Select ------ 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Position: Address: Employed To: Select ------ 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Supervisor: Reason for leaving: Salary: May we contact this employer?: Yes:     No: Company Name: Employed From: Select ------ 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Position: Address: Employed To: Select ------ 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Supervisor: Reason for leaving: Salary: May we contact this employer?: Yes:     No: Availability: Are you of age to serve or work in a licensed facility? Yes:     No: Do you have access to transportation past 11:00 pm? Yes:     No: What special qualifications do you have? Describe any of your work related skills, experience or training that relate to the position applied for. Available to work: Please Select Summer School Year Both Are you legally eligible to work in Canada? Yes:     No: Date available to begin work January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Will you work split shifts? Yes:     No: Please indicate days and hours available to work. Monday Tuesday Wednesday Thursday Friday Saturday Sunday 10 AM - 6 PM 6 PM - 2 AM Please Read Carefully I authorize investigation of all statements contained in this application and I hereby certify, to the best of my knowledge and belief, the answers given by me and the statements made are correct. I understand that any false information, or consequential omission is cause for immediate dismissal. Do not answer any questions that may, in your opinion infringe on your human rights. Reviewed by the Ontario Human Rights Commission, July 1991. By completing the following fields, you are electronically signing this form. Date:         Name:

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