Employment Application

All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin or handicap. All information provided herein will be kept confidential.

*Name

*Surname

*DOB

*Emergency contact (person not living with you)

Have you ever applied for employment with this Agency?

Yes

No

How many hours a week are you available for work?

*Are you legally eligible for employment in the United States?

Yes

No

How did you learn of our organization?

Online

Ad Agency

Employee

Other

Are you willing to work:

Evenings

Weekends

Both

*Position applying for:

*Upload Resume

*School/Institution

Location of School/Institution

Course of Study

Degree/Diploma

EDUCATION

CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED

List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.

"If you are a RN, LVN or CNA please enter your Licenses or certification information"

SPECIAL LICENSES, CERTIFICATIONS OR REGISTRATION

License/Certification Type

License/Certification #

State

Expiration Date

CPR Exp. Date

Last Physical Exam Date

Lab TB/Chest X-Ray Date

EMPLOYMENT

List the last five years employment history, starting with the most recent employer.

*Company Name

Address

City State Zip Code

Job Title and Describe your work

Employer Phone #

Reason for leaving

Date of Employment

Was your last name different from your present name during the above listed jobs?

Yes

No

If yes, what was your name?

Are you currently employed?

Yes

No

*Do you have reliable transportation?

Yes

No

PROFESSIONAL REFERENCES

Persons who can furnish information about job performance.

Reference 1

*Name

*Phone Number

Address

City, State, Zip Code

Reference 2

*Name

*Phone Number

Address

City, State, Zip Code

Reference 3

*Name

*Phone Number

Address

City, State, Zip Code

Final Step

*Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

Yes

No

Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full:

Are you capable of performing the job set forth in the job description?

Yes

No

If you answered NO, which job requirement can you not meet?

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency. I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.

*Signiture date

*Signature

ViV Employment Application

Employment Application

EDUCATION

CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED

PROFESSIONAL REFERENCES

Final Step