VNA Plus

Home Care Your Way

Serving Vanderburgh, Warrick, Posey and
Gibson Counties in Indiana
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Employment Application

Download Employment Application PDF OR complete the online application below and be sure to click “Submit Application” when finished!

Position(s) Applied For *:

How Did You Learn About Us?:

Visiting Nurse Plus Employee:
Other:

First Name *: Last Name *: M.I.:
Street Address *:
City *: State *: Zip *:
Telephone Numbers:
Home *: Cell:
Social Security Number:

On what date would you be available to work?

Are you available to work: Full TimePart-TimeCasual / PRN

List all names by which you have been known:
(This information will be used in requesting employment references and verification of information provided.)

If you are under 18 years of age, can you provide proof of your eligibility to work? YesNo
Have you ever filed an application with us before? YesNo
If yes, when?
Have you ever been employed with us before? YesNo
If yes, when?
Are you currently employed? YesNo
May we contact your present employer? YesNo
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
(Proof of citizenship or immigration status will be required upon employment.)
YesNo
Are you currently on "lay-off" status and subject to recall? YesNo
Can you travel if the job requires if? YesNo
Do you have a valid driver's license? YesNo
Have you ever had your driving privileges suspended or revoked? YesNo
Have you ever been convicted of or pled guilty to a felony or misdemeanor that has not been expunged by a court? YesNo
If yes, explain: Offense: When:
Disposition:
Education
High School: Years completed: 9101112
Did you graduate? YesNo Degree:
Describe Course of Study
Undergraduate College / University: Years completed: 1234
Did you graduate? YesNo Degree:
Describe Course of Study
Graduate / Professional: Years complete: 1234
Did you graduate? YesNo Degree:
Describe Course of Study
List any licenses and/or certifications held: Type: State: Expiration Date:
References
(Complete Thoroughly)
Give name, address and telephone number of three references who are not related to you and are not previous employers.
Full Name:
Address: Phone:
Best time to contact: Alt. Phone:
Full Name:
Address: Phone:
Best time to contact: Alt. Phone:
Full Name:
Address: Phone:
Best time to contact: Alt. Phone:
Are you currently under any legal or contractual restrictions, including but not limited to, confidentiality, non-compete that would prevent you from accepting employment with Visiting Nurse Plus? YesNo
If yes, please explain:
Have you ever been discharged or asked to resign from a job? If so, please explain:
Previous Employment
Employer: Phone:
Address: Supervisor:
Job Title Starting Salary: $ Ending Salary: $
Responsibilities:
From: To: Reason for Leaving:
Employer: Phone:
Address: Supervisor:
Job Title Starting Salary: $ Ending Salary: $
Responsibilities:
From: To: Reason for Leaving:
Employer: Phone:
Address: Supervisor:
Job Title Starting Salary: $ Ending Salary: $
Responsibilities:
From: To: Reason for Leaving:
List professional, trade, business or civic activities and offices held.
(You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, or disability or other protected status.)
Special Skills and Qualifications
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.

Applicant's Initials:

Date:

AN EQUAL OPPORTUNITY EMPLOYER

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.

Visiting Nurse Plus > Employment > Employment Application