Position(s) Applying For: *

Date *

Employment Availability: *

Full-Time   Part-Time   PRN  

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

Employee Referral (please list name) Newspaper Ad (please list name) Walk-In
Other

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

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:

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:

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:
Certified Nursing Assistant
Nurse Aide
Personal Care Aid
Companion

Name

Address

Did you graduate?
YES
NO

Type of Diploma/Degree/Cert

Major/Minor fields of Study

Name

Address

Did you graduate?
YES
NO

Type of Diploma/Degree/Cert

Major/Minor fields of Study

Name

Address

Did you graduate?
YES
NO

Type of Diploma/Degree/Cert

Major/Minor fields of Study

Name

Address

Did you graduate?
YES
NO

Type of Diploma/Degree/Cert

Major/Minor fields of Study

Name

Address

Did you graduate?
YES
NO

Type of Diploma/Degree/Cert

Major/Minor fields of Study

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.

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?

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?

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?

Full Name

Relationship

Company

Phone

Address

Full Name

Relationship

Company

Phone

Address

Full Name

Relationship

Company

Phone

Address

I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for deniel of employment or discharge.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between the company and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the company unless made in writing. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and that the company retains the same right.

I understand that, if employed, policies and rules that are issued are not conditions of employment and that the employer may revise policies or procedures in whole or in part at any time.

I understand that, if I am employed, I will be required to provide proof of identity and eligibility for employment in the United States (Ex: driver’s license, Social Security card, birth certificate, and/or Citizenship and Immigration Service Documents) and a current copy of my DMV report. Some applicants must also furnish current PPD results and CPR validation.

I understand that my application will be active for a period of 90 days for open positions within the company for which I am qualified. After the period of 90 days, I understand that I must submit a new application packet.

I certify that I have read, understand, and accept all terms of the foregoing Applicant’s Agreement and Certification Statements.

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: *