Employment Application

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.

Please complete all fields.

Position you are applying for:

First Name -- Middle Initial -- Last Name

Mailing address:
City, State, Zip: ,

Email address:

Daytime phone:
Evening phone:

Do you have your own transportation? NoYes
Is your vehicle insured? NoYes
Do you have a valid driver’s license? NoYes

Maiden Name(s)/Aliases (Please list other names or aliases by which you have been known)

Have you been previously employed by VNASWR? NoYes

(If yes, complete the following)
Position -- Dates of Employment
Position -- Dates of Employment

Where did you hear about this position? (required)

Agency website:
Employee Referral (Please give employee name)
Other website:
Other (Please specify)

Education

Name of School: -- Address:
Degree/Area of Study: -- Years Completed: -- Graduated: NoYes

Name of School: -- Address:
Degree/Area of Study: -- Years Completed: -- Graduated: NoYes

Name of School: -- Address:
Degree/Area of Study: -- Years Completed: -- Graduated: NoYes

Name of School: -- Address:
Degree/Area of Study: -- Years Completed: -- Graduated: NoYes

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.)

Employer (Company name): -- DATE STARTED: -- DATE ENDED:
Employer Address (Street, City, State, Zip Code):
Employer's Telephone: -- Supervisor's Name -- STARTING SALARY: -- ENDING SALARY
Position/Duties: -- Full TimePart Time
Reason for leaving:

Employer (Company name): -- DATE STARTED: -- DATE ENDED:
Employer Address (Street, City, State, Zip Code):
Employer's Telephone: -- Supervisor's Name -- STARTING SALARY: -- ENDING SALARY
Position/Duties: -- Full TimePart Time
Reason for leaving:

Employer (Company name): -- DATE STARTED: -- DATE ENDED:
Employer Address (Street, City, State, Zip Code):
Employer's Telephone: -- Supervisor's Name -- STARTING SALARY: -- ENDING SALARY
Position/Duties: -- Full TimePart Time
Reason for leaving:

Employer (Company name): -- DATE STARTED: -- DATE ENDED:
Employer Address (Street, City, State, Zip Code):
Employer's Telephone: -- Supervisor's Name -- STARTING SALARY: -- ENDING SALARY
Position/Duties: -- Full TimePart Time
Reason for leaving:

Employer (Company name): -- DATE STARTED: -- DATE ENDED:
Employer Address (Street, City, State, Zip Code):
Employer's Telephone: -- Supervisor's Name -- STARTING SALARY: -- ENDING SALARY
Position/Duties: -- Full TimePart Time
Reason for leaving:

Additional work history:

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? NoYes
If yes, what is the date of reinstatement? (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? NoYes
(Proof of citizenship and/or immigration status is required upon employment.)

Authorization

Please read this authorization carefully, then sign below.

I authorize all persons, schools, employers and organizations mentioned in this application to provide VNA & Hospice of the Southwest Region (VNASWR) 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.

The authorization: includesdoes not include my present employer

If employed by VNASWR I will abide by its rules and regulations. I understand that each individual’s employment at VNASWR 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.

VNASWR 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.

Typing your complete legal name into the box below will serve as your valid signature on this form.

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