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Applicant Information

Position(s) Applying For: *
Date *
Employment Availability: *
     
E-mail *
Last Name: *
First Name:*
M.I.
SSN
Street Address
Apartment/Unit #
City
State
Zip
Current Home Phone *
Current Cell Phone
Name of Back-Up Person to Call
Home/Cell Phones

How did you come to apply?




If hired, please list the date you would be able to start work:

Questions related to eligbility and credentials

Are you 18 years of age or older?
Are you legally eligible for employment in this country?
Has the U.S. Department of Health and Human Services ever excluded you as a provider of Medicare or Medicaid services? (OIG Exclusion List)
Have you ever been convicted of a Barrier Crime in or out of the Commonwealth of Virginia?
(Refer to list on Sworn Disclosure Document)
If yes, explain where, when, the charge, and the sentence:

Driver's License

Do you possess a valid current driver's license (transportation is a required essential function of the job)?
If yes, please provide your Driver's License Number:
Have you ever been convicted of a moving traffic violation or other crime in or out of the Commonwealth of Virginia?
If yes, explain where, when, the charge, and the sentence:

Professional License

Do you hold a current professional license?
If yes, list the type:
(CNA, RN, LPN, PT, PTA, OTA, COTA, SLP)
License Type
License Number
License Expiration Date
(Application must provide copies of current professional licenses when he/she submits application.)

Mark any of these that apply to you:





Work Availability


Education


High School

Name
Address
Did you graduate?

Type of Diploma/Degree/Cert
Major/Minor fields of Study

College/University

Name
Address
Did you graduate?

Type of Diploma/Degree/Cert
Major/Minor fields of Study

College/University

Name
Address
Did you graduate?

Type of Diploma/Degree/Cert
Major/Minor fields of Study

Graduate School

Name
Address
Did you graduate?

Type of Diploma/Degree/Cert
Major/Minor fields of Study

Others (Business, Technical, etc.)

Name
Address
Did you graduate?

Type of Diploma/Degree/Cert
Major/Minor fields of Study


Work Record

Start with your most recent employer; complete all spaces provided. Indicate if you were employed under a different name. Account for any time during your work experience that you were unemployed by stating the nature of your activities. Attach an additional sheet if necessary.

Previous Employment #1

Company
Phone
Supervisor
Address
Title
Starting Salary
Ending Salary
Responsibilities
Date From
Date To
Reason For Leaving
May we contact your previous supervisor for a reference?

Previous Employment #2

Company
Phone
Supervisor
Address
Title
Starting Salary
Ending Salary
Responsibilities
Date From
Date To
Reason For Leaving
May we contact your previous supervisor for a reference?

Previous Employment #3

Company
Phone
Supervisor
Address
Title
Starting Salary
Ending Salary
Responsibilities
Date From
Date To
Reason For Leaving
May we contact your previous supervisor for a reference?

References

Please list three professional references.

Reference #1

Full Name
Relationship
Company
Phone
Address

Reference #2

Full Name
Relationship
Company
Phone
Address

Reference #3

Full Name
Relationship
Company
Phone
Address



JOB APPLICANT'S AGREEMENT AND CERTIFICATION


NOTICE TO APPLICANTS: If you require an accommodation because of a physical or mental disability in order to participate in any phase of the application process, please make that fact known to the individual processing your application. If you are required to take any pre- employment screening tests and you require an accommodation because of a physical or mental disability to enable you to take or successfully complete such a test, please make that fact known in advance to the test administrator. If an offer of employment is made and, because of a physical or mental disability, you will need an accommodation to perform any essential job functions, please make that fact known to the individual processing your application.

Statements made by applicants for employment on this application form will be verified for accuracy. This Agency offers equal employment opportunities to all persons without discrimination regardless of race, color, sex, religion, national origin or ancestry, disability, marital status, age (over 18 years), medical condition, physical or mental handicap, pregnancy, citizenship status, Vietnam era veteran status, or any other legally protected status.

Signature of Applicant: *
Date: *