NAME OF CANDIDATE:
FILE: i
Page 1 of 5
ADDITIONAL FORM FOR LIVE-IN CAREGIVER 1. Please provide your phone numbers where you can be contacted during the day; also include your email address. Area code
Number
Email Address
Current Mailing Address
Provide the name, address and telephone number of any employment agency or recruitment agency, or any other third party, involved in arranging your job offer as a live-in Caregiver or otherwise involved in facilitating your application for a work permit as a live-in caregiver or your placement as a live-in caregiver.
Name of organization/ person/ agency involved – involved – outside outside Canada
Tel Number
Address
Valid POEA license? (circle one) Yes No
Legal name of organization/ person(s) / agency involved involved - in Canada
Tel Number
Address
Province of business license
Education and training Information: 2. On what basis are you submitting your application? Caregiver course
Employment experience
Educational background (nursing degree, etc.)
3. Details of your education – education – secondary secondary and post -secondary: Dates From
To
DD MM YYYY
DD MM YYYY
DD MM YYYY
DD MM YYYY
Name, address and telephone number of school
Type of degree /certificate/diploma issued
Number of credits/units obtained
* Use additional sheets if necessary 4. Language Ability and Caregiver Skil ls/Knowledge: I have an appointment to take the S.P .E.A.K Test on I am proving alternate evidence of Language Ability and caregiver skill/knowledge. I understand that my application will be assessed on the basis of documentation provided and that the onus is on me to establish that I meet the requirements on paragraphs 112(d) and 200(3)(a) of the IRPR.
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5. Please provide the name and address of the school where you attended caregiver training. Name of School
Address
6. What is the exact duration of your caregiver training? From DD
To
MM
YYYY
/
DD
/
MM
YYYY
/
/
7. What time and days of the week did you attend your classes? Time
Day
From
To
Monday
AM / PM
AM / PM
Tuesday
AM / PM
AM / PM
Wednesday
AM / PM
AM / PM
Thursday
AM / PM
AM / PM
Friday
AM / PM
AM / PM
Saturday
AM / PM
AM / PM
Sunday
AM / PM
AM / PM
You must provide complete, truthful and accurate information. The information provided may be verified. Providing incomplete, false or misleading information will likely result in a refusal of your a
lication.
8. Did you do any on-the-job training or practicum? If yes, please indicate the exact duration, time and days of the week of your on-the-job training or practicum. Yes (fill out table below) From DD
MM
/
/ /
/
No To
YYYY
DD
OJT Institution / Days of the Week / Time OJT Started and Ended (EXAMPLE: “Rizal Hospital, Mon-Fri, 8am – 5pm”)
MM
/
YYYY
/
/
/
/
/
/
/
* Use additional sheets if necessary 9. If you have a degree in Nursing, are you licensed? Yes PRC#
*Please attach a copy of your nursing degree and license
No
Page 3 of 5 10. Employment details for the last 10 years, including self-employment: Dates
Name, address and telephone number of employer
From
To
DD MM YYYY
DD MM YYYY
Your position
Monthly salary
* Use additional sheets if necessary 11. Travel Information: Do you have any previous overseas travels in the last ten years? Yes (fill out table below) No Duration Country
From MM
DD
YYYY
To MM
DD
YYYY
/
/
/
/
/
/
/
/
/
/
/ /
* Use additional sheets if necessary
*Important: You must provide a police certificate from every country where you have resided for 6 months or th more since your 18 birthday, including the Philippines. For the Philippines, you must provide a recent NBI clearance with dry seal and thumbprint, issued within the last 3 months. You must provide complete, truthful and accurate information. The information provided may be verified. Providing incomplete, false or misleading information will likely result in a refusal of your application. Personal Information: 12. What is your current marital status?
Single Annulled
Married Widowed In a common-law relationship
Legally Separated
13. Please provide details about your family members: Name
Relationship
Date of birth
Spouse / Common-law partner
DD / MM / YYYY / /
Son / Daughter
/
/
Place of residence (complete address)
Occupation
Page 4 of 5
Father
DD / MM / YYYY / / /
/
/
/
/
/
/
/
/
/
/
/
/
/
Mother
Brother/Sister
Brother/Sister
Brother/Sister
Brother/Sister
Brother/Sister Brother/Sister
* Use additional sheets if necess ary 14. Please list any of your relatives living in other countries (i.e. not in the Philippines): Name Country of residence
Exact relationship to you
15. Did you use an agency/third party for this application? Yes (fill out table below and submit authorization of representative form, if applicable)
No
Name of Agency
Address
16. Are you related to your prospective employer in Canada? Yes Indicate Relationship to him/her: SISTER
Contact Number
No
17. Have you been in a direct contact 9e-mail, phone, other) with your prospective employer? 18. Type of care you will provide (check all applicable)
Child(ren)
19. Number of person receiving care (indicate number) person(s)
child(ren),
Elderly
Yes
No
Disabled
elderly person(s), and/or
disabled
Page 5 of 5 20. Does your prospective employer currently employ a live -in caregiver?
Yes
No
21. Please list all the members of the household where you will be providing care, and their relationship to you prospective employer, and identity which members require care and whether any have any special needs. Name of household member (and relationship to prospective employer)
Care Required?
Age
Please describe any special needs (eg, Disability, medical condition, other)
(Employer) Yes / No (Spouse) Yes / No (Child)
(
)
Yes / No Yes / No
(
)
Yes / No
(
)
Yes / No
(
)
Yes / No
I declare that I have answered all required questions in this questionnaire and in my application fully and truthfully.
____________________________________ Printed Name and Signature of Applicant
_________________ Date
Please note that failure to complete all required questions will result to delays in the processing of your application
