Autorisation – Questionnaire médical – Anglais BOLASINGA Étape 1 sur 4 25% INFORMATIONIdentification number that you receive from the RH :* Job Title :* Please note that only the answers related to the requirements of the position you are applying for will be considered for the redaction of the report. Specify company name you applying for ? IDENTIFICATIONLast name :* First name : Date of Birth :*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Format de la date (dd/mm/yyyy)Province :*AlbertaColombie-BritanniqueManitobaNouveau-BrunswickTerre-Neuve et LabradorTerritoires du Nord-OuestNouvelle-ÉcosseNunavutOntarioÎle du Prince-ÉdouardQuébecSaskatchewanYukonPhone 1 :*Phone 2 : Best time to contact you :* AM PM Night Others AUTORISATIONAuthorization :* I declare having read the pre-employment medical questionnaire attached to this letter, I agree to answer it by telephone and I undertake to provide exact and complete answers to the questions it contains. I acknowledge that the medical clinic may request clarification of my answers to the questions contained in this pre-employment medical questionnaire and, if applicable, agree to provide accurate and complete information. In addition, I authorize the medical clinic to send to the applicant the report that will be written based on my answers and details, including its conclusions, as well as all the information on my state of health and I understand that this report will belong to the applicant and that any request for a copy should be addressed to the latter. Finally, I acknowledge that my answers will be used to determine whether my state of health is compatible with the job I applied for and, therefore, I acknowledge that giving false or misleading information could justify the claimant's not hire me or break my employment relationship. Candidate signature : Δ
