Client (Employer) Registration 1/3

IMPORTANT: Placement Fees apply when offer is made to an applicant.

Basic Informations First Name:

Last Name:

Login name (max 6 characters):

Password:

Confirm password:

Full Address:

City:

Postal Code:

Province:

E-mail:

Home phone:

Cell phone:

Skype:

CRA Payroll account#:

Fax:

Closest major intersection:

Client Occupational Information Profession:

Phone:

Client's Spouse Information Client's spouse name:

Profession:

Phone:

Are you or your spouse working from home?
Yes No

Date of position to start Date of position to start: Flexible starting date? Yes No
Need month:
Length of employment:

Children / Elderly / Disabled Info

Enter age of .....

1. Person:	Sex:	Birthdate:	Wt.^%: kg	*Sp Need^: Yes**
2. Person:	Sex:	Birthdate:	Wt.^%: kg	*Sp Need^: Yes**
3. Person:	Sex:	Birthdate:	Wt.^%: kg	*Sp Need^: Yes**
4. Person:	Sex:	Birthdate:	Wt.^%: kg	*Sp Need^: Yes**

^*Disabled / Special needs required.
^%If the job requires lifting (elderly/ disabled) specify the weight of the patient.