Employment Application

  • (This information will be used in requesting employment references and verification of information provided.)
    (Proof of citizenship or immigration status will be required upon employment.)

  • References

  • Previous Employment

  • (You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, or disability or other protected status.)
  • Summarize special job-related skills and qualifications acquired from employment of other experience.
  • Applicant Certification and Agreement

    I certify that the information provided in this application and any other resume furnished by me is true and complete. I authorize an investigation of all statements contained in my application for employment and understand that any false or misleading statements or material omission are cause for refusal to hire or separation of employment, if employed. I hereby authorize former and present employers, except as I have otherwise indicated in writing, as well as physicians, medical personnel, references and others to provide or verify any information they have regarding me or my employment with them to Visiting Nurse Plus (hereinafter called the “Agency”) or its representatives and release them from any liability arising from the furnishing of any employment history or medical information to the Agency.

    I further agree and understand that except as governed by existing federal, state or local law, where applicable my employment or an offer of employment establishes no guarantee or promise of continued employment or set hours or work or any other obligation on the part of the Agency beyond pay for actual work performed at the agreed upon rate and that the employment relationship may be terminated at any time, by myself or the Agency, at either party’s option and will.

    I understand that, if hired, the needs of the Agency may require that I be assigned increased hours, decreased hours, shift work, overtime work, weekend work, rotation shifts or other work schedule arrangements or changes in my work schedule or hours and I hereby agree to accept any such work schedule or hours or any such changes in work schedule or hours as a condition of employment with the Agency.

    If hired, I agree to acquaint myself and become familiar with the policies of the Agency as may from time to time be amended. I agree to protect the confidence and privacy of any and all information which pertains to the conduct of the Agency’s business. I understand that only the Executive Director of Agency may amend this Agreement and that such amendment must be in writing and signed and dated by both parties.
  • 8 + 5 =

    It is the policy of Visiting Nurse Plus to provide employment, training and development, compensation, promotion, and all other conditions of employment without regard to race, creed, color, religion, sex, sexual orientation, age, physical or mental disability, citizenship, national or ethnic origin, martial status, genetic information, or other basis prohibited by law. You may request any needed accommodations in order to complete this form.