APPLICATION FOR EMPLOYMENT - Visiting Nurse & Hospice Care

222 E. Canon Perdido St.Santa Barbara, CA 93101Tel: (805) 965-5555Fax: (805) 963-2375www.vnhcsb.orgAPPLICATIONFOR EMPLOYMENTINSTRUCTIONSCompletion of this form is a required part of the application process for all jobs. All requested information must be written onthe application form itself. Resumes or attachments may be included, but cannot be substituted for an application form. It isimportant to answer all questions on the application form fully and accurately. Failure to do so may disqualify an individual frombeing considered for a position, or if hired, may result in termination of employment.We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, sexual orientation,marital or veteran status, the presence of a non-job-related medical condition or handicap any other legally protected status.(PLEASE PRINT)Positions(s) Applied For: □ Full Time □ Temporary or Per Diem□ Part Time □ Other________________Date of ApplicationHow Did You Learn About Us?□ Advertisement (Specify: ___________________) □ Friend _____________________ □ Walk-in□ Employee ( Name:________________________) □ Relative____________________ □ Other _________________________Last Name First Name Middle NameAddress Number Street City State Zip CodeEmail address:Telephone Number(s)(Home) (Work) (Mobile)Social Security Number│ │Are you currently employed? Yes No May we contact your present employer? Yes NoWhat days are you available for work?What hours are you available for work?If applying for temporary work, during what period of time will you be available?________________________________________________________________________From______________To_______________Are you available to work weekends? Yes NoAre you available to work evenings? Yes No Are you available to work nights? Yes NoWould you be available to work overtime, if necessary? Yes NoIf hired, what date can you start work?_____________________PERSONAL INFORMATIONHave you ever applied or worked for the VNHC before? If yes, when? __________________________ Yes NoDo you have any friends or relatives working for VNHC? Yes NoIf yes, name(s) and relationship(s)_____________________________________________________________If hired, would you have a reliable means of transportation to and from work? Yes No1

Are you at least 18 years old? Yes No(If under 18, hire is subject to verification that you are of minimum legal age and have appropriate work permits.)Do you have any commitments to another employer that may affect your employment with us? Yes NoIf yes, please provide further information__________________________________________________________________________________________________________________________________________________________If hired, can you present evidence of your U.S citizenship or proof of your legal right to live and work in this country? Yes NoDo you have any limitation on your ability to perform the duties of the job? Yes NoIf yes describe the conditions and the nature of your work limitations___________________________________________________________________________________________________________________________________(Note: All new hires are subject to passing a physical examination and a drug test.)Have you been convicted of a criminal offence? Yes NoIf yes, please briefly describe the circumstances of your conviction, indicating the date, nature and place of the offence anddisposition of the case. Please state whether the crime was a misdemeanor or a felony. Applicant may omit any convictions for thepossession of marijuana (except for the convictions for the possessions of marijuana on school grounds or possession ofconcentrated cannabis) that are more than (2) years old, and any information concerning a referral to, and participation in, anypretrial or post trial diversion program. A conviction will not necessarily disqualify you from employment. No applicant will bedenied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, thesurrounding circumstances, and the relevance of the offense to the position(s) applies for may be considered.) Do not include arrestswithout convictions, or convictions for misdemeanors for which you have successfully completed probation or were otherwisedischarged.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Why do you think you are qualified for this position?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________EDUCATION, TRAINING AND EXPERIENCESCHOOLHigh School/EquivalentVocational/BusinessHealth Care(Special Courses)College/UniversityGraduateSchoolNAME AND ADDRESSYEARSCOMPLETEDMAJORDIPLOMADEGREECERTIFICATE2

INDICATE ANY FOREIGN LANGUAGES YOU CAN SPEAK, READ/OR WRITEFLUENT GOOD FAIRDo you have any other experience, training, qualifications or skills which you feel make you especially suited for work at the VNHC?If so, please explain:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you currently licensed/certified in California for the job applied for? N/A Yes NoName of license/certification ___________________________________________________Expiration Date____________________Issuing state_____________________License/certification number ________________________________________________Has your license/certification ever been revoked or suspended? Yes NoIf yes, state reason(s), date of revocation or suspension and date of reinstatement _____________________________________________________________________________________________________________________________________________________REFERENCESList below five persons who have knowledge of your work performance within the last three years:Name: _______________________________________________Occupation: __________________________________________Home Telephone Number: (______) _______________________Work Telephone Number: (______) _______________________Relationship to you: ___________________________________Email Address: ________________________________________Cell Telephone Number: (______) _________________________Number of Years Acquainted: ____________________________Name: _______________________________________________Occupation: __________________________________________Home Telephone Number: (______) _______________________Work Telephone Number: (______) _______________________Relationship to you: ___________________________________Email Address: ________________________________________Cell Telephone Number: (______) _________________________Number of Years Acquainted: ____________________________Name: _______________________________________________Occupation: __________________________________________Home Telephone Number: (______) _______________________Work Telephone Number: (______) _______________________Relationship to you: ___________________________________Email Address: ________________________________________Cell Telephone Number: (______) _________________________Number of Years Acquainted: ____________________________3

Employer Dates Employed Worked PerformedFromToAddressTelephone Number(s)Hourly Rate/SalaryStarting FinalPosition/Job TitleSupervisorReason for LeavingIf you need additional space, please continue on a separate sheet of paper.Special Skills and QualificationsSummarize special skills and qualifications acquired from employment or other experience. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________*PLEASE READ, INITIAL ON THE LINE AT THE END OF EACH PARAGRAPH, AND SIGN BELOW*I certify that the information provided in this application is true and complete to the best of my knowledge. I furthercertify that I, the undersigned applicant, have personally completed this application. I understand that anyfalsification, omission, misrepresentation or concealment of information on this application, during interviews, or atany other time during the hiring process may result in rejection of this application or, if hired, may result in disciplineup to and including dismissal, regardless of the time elapsed before discovery. ______I hereby authorize Visiting Nurse & Hospice Care of Santa Barbara to thoroughly investigate my references, workrecords, and other matters related to my suitability for employment and, further, authorize my former and currentemployers to disclose to the company any and all letters, reports and other information related to my work history. Inaddition, I hereby release the company, my former employers and all other persons, corporations, partnerships andassociations from any and all claims, demands or liabilities arising out of or in any way related to such investigation ordisclosure. ______I understand that nothing contained in the application or conveyed during any interview which may be granted isintended to create an employment contract between me and Visiting Nurse & Hospice Care. I also understand that alloffers of employment are conditional upon satisfactory reference checks, completion of Visiting Nurse & HospiceCare’s standard confidentiality agreement and production of documents necessary for Visiting Nurse & Hospice Careto verify identity and work authorization in accordance with the USCIS form I-9. I also understand that a company paiddrug test and/or physical examination and background and/or credit check may be required and if performed,employment would be contingent upon satisfactory results. I also authorize Visiting Nurse & Hospice Care to conductany of the foregoing. ______I understand and agree that my employment is at-will and I may terminate my employment at any time without causeor notice; similarly, my employment may be terminated or my status changed (for example, my position may bechanged, I may be demoted, or my benefits may be changed) by the Company at any time without cause or notice. Ialso understand that this at-will agreement will remain in effect throughout the duration of my employment and mayonly be changed by a written agreement signed by the President/CEO of Visiting Nurse & Hospice Care. ______Applicant’s Signature: ____________________________________________Date: _____________________Print Name: ____________________________________________________ rev 6/105