Employment Application - Comprehensive — VNA & Hospice of the Southwest Region

Employment Application - Comprehensive

Step 1 of 5 - Application for Employment

VNA & Hospice of the Southwest Region is an Equal Opportunity Employer. We consider applicants for all positions without regard to race, religion, color, national origin, age, ancestry, gender, sexual orientation, marital status, veteran status, physical or mental impairment, medical condition or other legally protected status. Assistance in reviewing job opportunities and/or completing this employment application will be provided to persons with disabilities upon request.
Personal Information
Name*
First Middle Initial Last
Email*
Enter Email Confirm Email
Address*
Mailing Address City State ZIP Code
Daytime Telephone*
Evening Telephone
Do you have your own transportation?*
- Yes
- No
Is your vehicle insured?*
- Yes
- No
Do you have a valid driver's license?*
- Yes
- No
Maiden Name(s) and/or Aliases by which you have been known.
Have you been previously employed by VNAHSR?*
- Yes
- No
If yes, list previous position(s) and dates.*
Position Dates of Employment
Attach Resume/CV and Cover Letter (optional)
Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 10 MB, Max. files: 3.
If you attach files here, be sure to compete all other REQUIRED fields (marked with *) below in order to submit this application to VNA and Hospice.
Employment Preferences
Position Desired*
Scheduling Preferences
- Full-Time
- Part-Time
- Per Diem
Preferred Shifts
- Days
- Nights
- Evenings
- Overnights
- Weekends
Salary Desired
Salary
- Per Hour
- Per Year
How did you hear about this position?*
- VNA & Hospice Website
- Recruitment Website (Indeed/JobsInVT, etc.)
- Digital Ads Online
- Social Media
- Newspaper
- Employee Referral
- Job Fair
- Radio/TV
- Craig's List
- Other
Specify if 'Other'
Education
Please include high school through college or other institutions of learning. Click on the + sign to add as many institutions as needed.
Education History
School City / State Degree / Area of Study Years Completed Graduated?
Work History
(List all part-time/full-time positions in reverse chronological order with present or most recent position first. Use additional space provided below if necessary.)

Click on the + sign to add an employment record
Employment History (Leave no blanks)
Employer City/ State Supervisor Name&Phone Position/ Duties Start/ End Date Full/ Part Time

You may skip this section only if a resume/CV is attached that includes work history. To add up to 5 additional jobs, please click the + sign.
Special Qualifications/Skills
(List any additional skills or abilities you feel are relevant to the job for which you are applying. Include significant education, certifications, life and volunteer experiences.)
Additional Information
Have you ever been excluded from participating in any federal health care program?
- No
- Yes
If yes, what is the date of reinstatement?*
MM slash DD slash YYYY

(Please be prepared to present OIG letter of reinstatement.)
Are you prevented from becoming lawfully employed in this country because of visa or immigration status?
- No
- Yes
(Proof of citizenship and/or immigration status is required upon employment.)
Authorization
I authorize all persons, schools, employers and organizations mentioned in this application to provide VNA & Hospice of the Southwest Region (VNAHSR) with any and all information requested by the agency. I voluntarily release such persons, schools, employers and organizations from all liability for providing such information.
This Authorization*
- Authorizes VNAHSR to contact my present employer.
- DOES NOT authorize VNAHSR to contact my present employer.
If employed by VNAHSR I will abide by its rules and regulations. I understand that each individual’s employment at VNAHSR may terminate the employment relationship at any time for any reason, or for no reason with or without notice, at its option. Any oral or written statement by any member of company management which contradicts the “at-will” nature of the employment relationship as expressed herein is unauthorized and of no validity with the exception of a written statement made by the Executive Director.

VNAHSR specifically reserves the right to add to, delete from and modify personnel policies at its sole discretion at any time. Detailed information concerning company policies may be obtained by contacting Human Resources.

I understand that I will be asked to take a physical examination after an employment offer has been made and at any time during my employment at the option and expense of the company. I understand that medical records will be released only when required by law or subpoena, when authorized by myself in writing, or when a health care professional determines that I might cause harm to myself or others. I understand that a Vermont Criminal Information Center, Office of Inspector General, Adult and Child Abuse Protection Registry Check shall be required upon an offer of employment. All offers of employment are conditional based on the outcome of pre-employment physical, background and reference checks.

All the foregoing information supplied in the application is true and a full and completed statement of facts to the best of my knowledge. I understand that if any misrepresentation or falsification is discovered, it will constitute grounds for discharge. I understand that this application is neither an offer of nor a contract of employment nor is any provision in this application to be considered contractual in nature. Please ensure that all information is complete before signing. Incomplete applications will not be accepted.
Type your complete legal name in this box to serve as your official electronic signature.*
Today's Date*
MM slash DD slash YYYY
IMPORTANT NOTICE TO APPLICANTS: Once this page is successfully saved you will have completed page 1 of 5. YOUR APPLICATION WILL NOT BE RECEIVED until all 5 pages are completed and signed. Once page 1 has been accepted, please either save or go on to page 2 of 5.

Save and Continue Later

References
Thank you for applying at VNA & Hospice of the Southwest Region (VNAHSR) and providing us with a mandatory list of contact information for your 3 employment references. Please note that according to Vermont law, if in good faith you provide accurate, factual information, you are immune from liability.
Three references are required prior to employment.
Name of Applicant*
First Middle Last
Applicant Email*
Enter Email Confirm Email
Applicant Phone*
Applicant Address*
Street Address Address Line 2 City State ZIP Code
First Reference
You may skip this section only if a resume was attached that includes personal/professional references.
Contact Name
First Last
Phone
Email
How long have you known this person?
How do you know this person?
Second Reference
Contact Name
First Last
Phone
Email
How long have you known this person?
How do you know this person?
Third Reference
Contact Name
First Last
Phone
Email
How long have you known this person?
How do you know this person?
Authorization to Release Information
I hereby give VNA & Hospice of the Southwest Region permission to request information regarding my skills, work habits, attendance and any other pertinent information. It is my understanding that the information gained will be used in assessing my capabilities and potential success at VNA & Hospice of the Southwest Region. Your response will be kept in a confidential file.
Typed Name is Electronic Signature*
Date*
MM slash DD slash YYYY
IMPORTANT NOTICE TO APPLICANTS: Once this page is successfully saved you will have completed page 2 of 5. YOUR APPLICATION WILL NOT BE RECEIVED until all 5 pages are completed and signed. Once page 2 has been accepted, please either save or go on to page 3 of 5.

Save and Continue Later

Driving Record Verification
To be completed by applicant: Consent from current or prospective employee
This consent form must be filled out completely and signed by the current employee, prospective employee, contractor or volunteer and kept on file at the requesting organization.
Applicant's Full Name*
First Middle Last
Driver's License Info*
Date of Birth Operator's License Number State of Issue Expiration Date
I currently possess a valid driver’s license. I have not received a conviction violation or involvement in an accident, nor have I had my license suspended at any time during the past three years, other than the following:
Additional Driving Record Information
I hereby authorize the Department of Motor Vehicles to release to VNA & Hospice of the Southwest Region any information related to my driving record. I certify that I am currently employed or have been given a conditional offer of employment by VNAHSR.
(Prospective) Staff Signature*
Today's Date*
MM slash DD slash YYYY
IMPORTANT NOTICE TO APPLICANTS: Once this page is successfully saved you will have completed page 3 of 5. YOUR APPLICATION WILL NOT BE RECEIVED until all 5 pages are completed and signed. Once page 3 has been accepted, please either save or go on to page 4 of 5.

Save and Continue Later

This form is for use with the ON-LINE registry checking system ONLY
Vermont Agency of Human Services - Adult Protective Services - 103 S. Main Street - Ladd Hall - Waterbury, VT 05671-2306 - AND - Child Abuse Registry Unit - 103 S. Main Street - Waterbury, VT 05671-2401 - FORM C
This consent form must be filled out completely and signed by the current employee, prospective employee, contractor or volunteer and kept on file at the requesting organization. The Agency of Human Services reserves the right to audit these consent forms at any time.
Current or Prospective Employee, Contractor, or Volunteer Information
Name
First Last
Gender*
- Male
- Female
Address*
Street Address Address Line 2 City State ZIP Code
LAST 4 DIGITS of Social Security Number*
Phone*
Date of Birth*
Place of Birth*
Other FIRST names I have used, if any. (i.e. Nicknames, Aliases)
Other LAST names I have used, if any. (i.e. Maiden Names, Aliases)
By my electronic signature below, I hereby authorize release of any information of reports of abuse, neglect or exploitation substantiated against me and contained in the Vermont Adult Abuse Registry and/or the Vermont Child Protection Registry to: VNA & HOSPICE OF THE SOUTHWEST REGION
(Prospective) Staff, Contractor, or Volunteer Signature*
Today's Date*
IMPORTANT NOTICE TO APPLICANTS: Once this page is successfully saved you will have completed page 4 of 5. YOUR APPLICATION WILL NOT BE RECEIVED until all 5 pages are completed and signed. Once page 4 has been accepted, please either save or go on to page 5.

Save and Continue Later

Employment Application – Comprehensive

Employment Application - Comprehensive

Step 1 of 5 - Application for Employment

Personal Information

Employment Preferences

Education

Work History

Additional Information

Authorization

IMPORTANT NOTICE TO APPLICANTS: Once this page is successfully saved you will have completed page 1 of 5. YOUR APPLICATION WILL NOT BE RECEIVED until all 5 pages are completed and signed. Once page 1 has been accepted, please either save or go on to page 2 of 5.

References

Three references are required prior to employment.

First Reference

Second Reference

Third Reference

Authorization to Release Information

IMPORTANT NOTICE TO APPLICANTS: Once this page is successfully saved you will have completed page 2 of 5. YOUR APPLICATION WILL NOT BE RECEIVED until all 5 pages are completed and signed. Once page 2 has been accepted, please either save or go on to page 3 of 5.

Driving Record Verification

To be completed by applicant: Consent from current or prospective employee

IMPORTANT NOTICE TO APPLICANTS: Once this page is successfully saved you will have completed page 3 of 5. YOUR APPLICATION WILL NOT BE RECEIVED until all 5 pages are completed and signed. Once page 3 has been accepted, please either save or go on to page 4 of 5.

This form is for use with the ON-LINE registry checking system ONLY

Current or Prospective Employee, Contractor, or Volunteer Information

IMPORTANT NOTICE TO APPLICANTS: Once this page is successfully saved you will have completed page 4 of 5. YOUR APPLICATION WILL NOT BE RECEIVED until all 5 pages are completed and signed. Once page 4 has been accepted, please either save or go on to page 5.

Equal Employment Opportunity Statement

THIS FORM MUST BE COMPLETED AND SIGNED IN ORDER FOR US TO RECEIVE YOUR APPLICATION. Some information is optional, but the form must be submitted regardless of your responses. This is the last section of our job application. THANK YOU.

Military Service

Position	Dates of Employment

School	City / State	Degree / Area of Study	Years Completed	Graduated?

Employer	City/ State	Supervisor Name&Phone	Position/ Duties	Start/ End Date	Full/ Part Time

Date of Birth	Operator's License Number	State of Issue	Expiration Date