1. Your Name (required)

2. Date of Birth (required)

Age (required)

Gender (required)

 Male Female

3. Address (required)

4. Telephone# (required)

5. Email Address

6. Next of Kin Telephone

7. Marital Status

8. No. & Ages of children

9. Social Security# (required)

10. Driver's License (required)

 NA Class A Class B Class C

11. Expiry Date

12. Have you had any accidents in the last 3 years (required)

 NA Yes No

13. Have you ever committed a criminal offense? (required)
 Yes No

14. Have you ever been convicted of a crime? (required)
 NA Yes No

15. If the answer to questions 13 & 14 above is "Yes" please provide details. (required)

16. Provide a brief medical history of all accidents, hospitalizations, recurrent
illness, psychotics illness, where applicable.(required)

17. What type of employment you desire? (required)

 Full Time Partime Both

18. Date of Availability (required)

19. Positions of Interest (In Order of Preference)

20. Education (Schools attended)

21. Qualifications

22. Work Experience ex: Name Of Company | Position | Date Of Employment | Supervisor | Reason For Leaving

Qualifications must be supported by certified copies of certificates or the original
certificates must be presented to vouch accuracy of the copies.

23. Languages & Level of Fluency

English

Spanish

French

Other (Specify)

24. Skills & Competencies

25. Strengths

26. Weakness

27. Reasons why you should be selected

28. Name of three references (Name & Position)

12+11=? 

PLEASE SUBMIT A POLICE RECORD WITH YOUR APPLICATION TO:
J. Astaphan & Co. Ltd. 65 King George V St., Roseau

EMPLOYMENT APPLICATION DISCLAIMER AND ACKNOWLEDGEMENT

I certify that the information contained in this application is correct to the best of my knowledge. I understand that to falsify information is grounds for refusing to hire me, or for discharge should I be hired. I authorize any person, organization or company listed on this application to furnish you any and all information concerning my previous employment, eduction and qualifictions for employment. I also authorize you to request and receive such information. I AGREE