Location Applied At:   ---------- Fokus I Fokus II Fokus III Fokus IV

Date of application:   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 ,   2003 2004 2005

Date available:   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 ,   2003 2004 2005

Surname:     Given name(s):

Gender (Optional): M     F

Address:

City:      Postal Code:

Telephone: Home:      Work:

Social Insurance Number:
(Social Insurance Number may be left blank and submitted if hired.)

Position Applied For:

Salary Expected:

A POLICE CHECK WILL BE REQUIRED
(Please bring it to the interview.)

Person to contact in case of an emergency:

Phone Number:      Relationship:

Have you ever applied at Fokus?: No     Yes

If yes, when and where?:

How did you hear about Fokus Management Inc.?

Courses Completed:

Certification/Degree/Diploma Obtained:

Courses Completed:

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Courses Completed:

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Courses Completed:

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Company Name:

Position:

Reason for Leaving:

Date Started:

Date Left:

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References Phone Number:

Position:

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Position:

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Name:

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Address:

Relationship:

Phone Number:

Name:

Address:

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Phone Number:

Name:

Address:

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Phone Number:

MEDICAL NUMBER:
(Medical Number may be left blank and submitted if hired.)

Do you have any physical limitations which would affect your work here? No Yes

If yes, please explain:

INFORMATION RELEASE

I HEREBY AUTHORIZE
                                     (Name, Address and Phone Number of Your Doctor)

To Provide Fokus Management Inc., such Medical Information as may be required.

DATED      __________________________________________
                                                              SIGNATURE OF APPLICANT

1. If you had an important interview with a prospective employer, and on this day (45 minutes before leaving home), you discovered your car would not start, and you only had 60 cents total in monies.  How might you respond to the situation (give a brief description)?

2. You are in a store grocery shopping.  You notice a disabled person in a wheelchair who appears to be having difficulty reaching items off the shelf.  Would you offer this person some assistance?  If so, how would you approach the individual?  Give a brief description.

3a. Over the last week one tenant has consistently called you and requested that you perform a task assigned to another shift.  How would you respond?

3b. What further steps might you take?

4a. A tenant is scheduled to receive a specific service (i.e. supper) and when you arrive, they request that you do something else.  Both the scheduled service and the requested task would take approximately the same amount of time.  How would you respond to them?

4b. Who would you approach to help with the situation?