Available Start Date:
Interview by:
Instructions: Print clearly in black or blue ink. Answer all questions. Sign and date the form.
Please complete all questions.
Type of Position Applied for  
Location Applied for:    
Wage Expectation:    
Surname Given Name Middle
Apt./Suite # City
Province Postal Code Main
Home Phone
Email Address
Cellular or Pager
Who should we contact in case of an emergency? Name:
Home #
Cellular #
Are you eligible to work in Canada? Yes No
Are you at least 18 years of age? Yes No
How did you hear about Trillium Interim Staffing?
Have you ever worked or registered with other Staffing Agency?
Transportation: Transit Car Other
Are you currently employed? No or Yes – What are your working hours?
Availability: Day Afternoon Overnight
  Full Time Part Time  Temporary
Which following wok equipment do you own? Safety Shoe Safety Glass Hard hat
  Gloves Hearing Protection
Are you able to lift 25 to 50 lbs? Yes or No
Have you been convicted of a criminal offense that has not yet been pardoned? Yes No
If yes, please explain details:
What date are you available to start work?


Name and Address Of School Degree/Diploma Graduation Date
Skills and Qualifications: Licenses, Skills, Training, Awards
Employer: From: To:
Supervisor: Phone:
Email: Position Title:
Job Descriptions:
Reason for Leaving:
Employer: From: To:
Supervisor: Phone:
Email: Position Title:
Job Descriptions:
Reason for Leaving:
May we contact these employers for references? Yes No
Recognizing the importance of trust in an employee relationship and that Trillium will be relying on the information which I have provided to the company, by my signature on the application form, I:
Authorize the verification of the above information and any other necessary inquiries which may be needed to determine my suitability for employment.
Affirm that the above information is true to the best of my knowledge.
Acknowledge that misrepresenting or supplying false/inaccurate information may result in immediate rejection of my application or result in dismissal for cause.
Applicant’s Signature Date:
Please check each experience that applies to you
  Industrial Plastics Skilled Trades Maintenance
  Blow Mold Tool & Die Janitorial
  Grinding Injection Molding Carpentry Building Maintenance
  Rework Silk Screen Electrical Landscaping
  Inspection   Plumbing Machine Maintenance
  Painting Equipment Journeyman Custodian
  Constructions Jackhammer   Housekeeper
  Lumber Handling Saw Mechanics  
  Moving Furniture Bobcat Heavy Forklift
    Caterpillar Automotive Raymond Reach
  Warehouse Crane Apprentice Reverse Raymond Reach
  Shipping/Receiving Overhead Crane   Cherry Picker
  Palletizing   Food Service Pump Truck
  Loading/Unloading Welding Hospitality Pallet Truck
  Shipping Clerk Aluminum/Stainless Banquets Narrow Aisle
  Order Entry Arc Bartending Propane
  Inventory Sub-Arc Cooking Diesel
  Stocking Mig/Tig Dishwashing Gasoline
  Material Handling Class 1 Food Preparation Walkie
  Order Picking/Packing  B Pressure Laundry  
      Serving Tables Technical
  Printing & Bindery Machine Operator Busing Schematics
  Printing Press Machinist Smart Serve Training Soldering
  Bailer Extrusion Moulder   PC Board
  Collator Intrusion Moulder Other Skills Colour Codes
  Stitcher/Trimmer Lathe Cashier Electrical Assembly
  Folder Pipe Fitter Dispatcher Mechanical Assembly
  Shrink wrap/mail Punch Press Mailroom Micrometers
    Brake Press Delivery/Courier  
  Drill Press    
  Drop Press    
  Industrial Sewing Machine Operator  
Interview Comments
Email Address: (To whom the pdf wil be mailed)