Name *
Last
First
Middle
Address *
Street
City
State/Province
Zip/Postal Code
Telephone # *
Cell Phone # *
Emergency Contact: *
Name
Phone
Email Address *
Referred to us by*
Position(s) applied for * Companion Sitter Personal Care Aide Skilled Nursing Physical Therapy Occupational Therapy Speech Therapy Medical Social Worker Chaplain Other
Date Available *
Type of employment desired Full-Time Part-Time
Please specify days and hours of availability *
If currently employed, may we contact your employer? * Yes No
Rate of pay expected $ per hour *
Are you legally eligible for employment in the United States? * Yes No
Are you available to work overtime if required? * Yes No
Have you applied with this company before? * Yes No
Have you been employed at this company before? * Yes No
If yes, when? and at what location?
Do you have any friends or family employed at this location? * Yes No
Have you ever been convicted of a crime within or outside Virginia (but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law)? * Yes No
If yes, please explain *
Are you the subject of any pending criminal charges within or outside Virginia? * Yes No
If considered for hiring, will you agree to provide a criminal background check? * Yes No
If considered for hiring, will you agree to provide a current drivers license? * Yes No
List four (4) previous educational institutions attended, begining with the most recent.
School
City, State/Province
Graduated?
Degree(s)/Diploma(s) Earned
1.
2.
3.
4.
What Nursing or relevant designations, licenses or registrations if any, do you possess?
Type
Date of Most Recent Registration
Valid in State/Province?
Do you have the following: *
CPR Yes No Last Certified
First Aid Yes No Last Certified
Provide the following information beginning with the most recent employer:
Employer name Telephone number Dates employed from to Summarize the type of work performed and job responsibilities Address Job Title Hourly rate/salary starting $ per Hourly rate/salary final $ per Immediate supervisor and title and phone number Reason for leaving May we contact for reference? Yes No Later
List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).
Relationship
Years aquainted
Phone Number
I certify that all the information I have provided is true, complete and correct.
The information contained within this application or any cover letter or resume attached is not shared with any third parties. The information is used by the employer only as an aid in the hiring decision making process. The applicant, by signing the application gives the employer consent to collect the information contained herein and use for the purpose specified.
I authorize this company to investigate all statements contained on this application. I understand that any misrepresentation or omission of facts called for is cause for immediate disqualification and/or if employed, immediate dismissal.
I understand that if I am hired, I will be required to provide criminal background check at my cost, proof of identity and legal authority to work in United States , proof of certifications or educational qualifications.
Furthermore, I understand and agree that if employed, I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same rights to terminate my employment at any time, with or without prior notice, except as may be required by law. This application does not in any way constitute an agreement or contract for employment.
Applicant's Signature *