APPLICATION FOR EMPLOYMENT - Visiting Nurse & Hospice Care

More documents

Recommendations

Info

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 <strong>Care</strong>(Special Courses)College/UniversityGraduateSchoolNAME AND ADDRESSYEARSCOMPLETEDMAJORDIPLOMADEGREECERTIFICATE2
INDICATE ANY <strong>FOR</strong>EIGN 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
Page 1: 222 E. Canon Perdido St.Santa Barba

APPLICATION FOR EMPLOYMENT - Visiting Nurse & Hospice Care

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?