Basic Profile

First Name *

Last Name *

Phone *

Email *

Date of birth *

Address

Street Address *

City

State

Country

Postal code

Do you have a vehicle?

YES

Have you worked for a temporary placement agency before?

YES

Years of Experience

Please indicate the YEARS OF EXPERIENCE you have in the following jobs (If NONE leave it BLANK):

Construction Labour
Form Stripping
Carpentry
Concrete / Cement
Drywall
Flagging
Heavy Equipment
Forklift
Safety Officer
Warehousing
Painting
Moving
Roofing
Landscaping
Cleaning
First Aid Attendant (+level)

Medical Questionnaire (CONFIDENTIAL)

We request basic medical information to help us find a work position and environment suitable to your capacity, thus minimizing the risk of serious injury to yourself, your colleagues, and/or everyone else involved.

Do you have a Heart Condition?

YES

Do you have Epilepsy?

YES

Do you have a history of Back Problems?

YES

Do you have Diabetes?

YES

Do you have High Blood Pressure?

YES

Have you ever had an Eye Injury?

YES

Are you Bondable?

YES

Have you ever had and Major Joint Injuries?

YES

Have you ever had a Head Injury?

YES

Do you have a Hearing Problem?

YES

Have you had any Previous Fractures?

YES

Do you have any Allergies? *

YES

Do you have a Hernia?

YES

Do you have Dizzy Spells?

YES

Are you currently taking any Medications? *

YES

Are you Medically Cleared and Fit to Work with No Restrictions?

YES

*If “YES” please indicate your allergies

**If “YES” please indicate what medications

Is there any present medical condition or other information we should be aware of including injuries or chronic ailments?

Please fill out an EMERGENCY CONTACT

(I authorize JPD Staffing Inc. to contact the following person(s) on my behalf in case of an emergency)

Contact Person 1

First Name
Last Name
Phone Number

Contact Person 2

First Name
Last name
Phone Number

Dispatch Policy

I understand that if I wish to be eligible for dispatch work ("on-call" status) for a particular day, I will contact the JPD Staffing Inc. office and indicate my dispatch availability. If I cannot be contacted, I forfeit my "on-call" status position to the next available worker contracted. I understand that all work is on a casual basis and that I do not commence work until I have attended and started working at the location to which I have been dispatched. I also make clear my understanding that none of the above is a guarantee of work.

By submitting this form, I declare that all statements in this application are deemed accurate to the best of my knowledge. Any omission by myself or any misrepresentation is grounds for immediate dismissal. My employer can request an examination by a physician as required.