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.

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 outside
Canada
Tel Number Address Valid POEA license? (circle
one)
Yes No

Legal name of organization/
person(s) / agency 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 secondary and post-secondary:

Dates
Name, address and telephone number of school
Type of degree
/certificate/diploma
issued
Number of
credits/units
obtained

From To
DD MM YYYY


DD MM YYYY



DD MM YYYY


DD MM YYYY



* Use additional sheets if necessary

4. Language Ability and Caregiver Skills/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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Area code

Number

Email Address

Current Mailing Address


5. Please provide the name and address of the school where you attended caregiver training.

6. What is the exact duration of your caregiver training?

7. What time and days of the week did you attend your classes?

Day
Time
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








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) No

From To OJT Institution / Days of the Week / Time OJT Started and Ended
(EXAMPLE: Rizal Hospital, Mon-Fri, 8am 5pm)
DD MM YYYY
/ /
DD MM YYYY
/ /

/ / / /
/ / / /
* Use additional sheets if necessary

9. If you have a degree in Nursing, are you licensed?
Yes No


*Please attach a copy of your nursing degree and license













Name of School


Address



From To
DD MM YYYY
/ /
DD MM YYYY
/ /
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.
PRC#
Page 3 of 5

10. Employment details for the last 10 years, including self-employment:

Dates Name, address and telephone number of
employer
Your position

Monthly
salary From To
DD MM YYYY


DD MM YYYY







* 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

Country
Duration
From
DD MM YYYY
To
DD MM YYYY
/ /
/ /

/ / / /

/ / / /
* Use additional sheets if necessary

*Important: You must provide a police certificate from every country where you have resided for 6 months or
more since your 18
th
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.







Personal Information:
12. What is your current marital status? Single Married Widowed Legally Separated
Annulled In a common-law relationship

13. Please provide details about your family members:

Name Relationship Date of birth Place of residence
(complete address)
Occupation

Spouse /
Common-law
partner
DD / MM / YYYY
/ /

Son / Daughter / /







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.




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Father
DD / MM / YYYY
/ /

Mother
/ /

Brother/Sister
/ /

Brother/Sister
/ /

Brother/Sister
/ /

Brother/Sister
/ /

Brother/Sister
/ /

Brother/Sister
/ /


* Use additional sheets if necessary

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

Contact Number


16. Are you related to your prospective employer in Canada?
Yes No


17. Have you been in a direct contact 9e-mail, phone, other) with your prospective employer? Yes No

18. Type of care you will provide (check all applicable) Child(ren) Elderly Disabled

19. Number of person receiving care (indicate number) child(ren), elderly person(s), and/or disabled
person(s)











Indicate Relationship to him/her: SISTER
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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