Partnership Application Employment Application First Name * Last Name * Email * Address Street Address City State Zip Code Cell Phone * Position applying for: * RN CNA PCA Companion Administrative Assistant Care Manager High School City State Dates attended high school Did you graduate high school? * Yes No Other Education Type of License or Certification Currently Held (RN, LPN, CHHA, CNA, PCA, etc.) Do you have a valid driver’s license? * Yes No Do you have your own vehicle and auto insurance? * Yes No Have you ever been convicted of a crime (felony or misdemeanor), including sex-related or child-abuse related offenses? * Yes No If yes, please explain: * What tickets do you have for motor vehicle violations - type and date? * Current / Most Recent Employer’s Name Job Title Employed From Employed To Reason for Leaving Starting Wage Ending Wage Please describe your caregiving experience Availability How many hours per week do you prefer to work? All staff are required to work four weekend days each month. Are you available for weekend work? Yes No Please indicate specific times each day you would be available to work Monday Tuesday Wednesday Thursday Friday Saturday Sunday Can we assign you to a client who has a cat? Yes No Can we assign you to a client who has a dog? Yes No How did you hear of this position? newspaper ad, friend, co-worker APPLICANT’S AUTHORIZATION FOR RELEASE OF INFORMATION Authorization I (Applicant) hereby authorize Virginia Home Care Partners, to request and receive from all employers, within 3 years of the date of this application, any and all pertinent information concerning my employment and its termination, including the reasons for such termination. I also give Virginia Home Care Partners permission to obtain medical information of mine as required by the hiring standards. I hereby release said companies, organizations, agents, individuals, and Virginia Home Care Partners from any liability for any damage whatsoever resulting from the giving of such information. By checking here I agree to the above Authorization * Agree APPLICANT’S CERTIFICATION & AGREEMENT: Certification I certify that any and all statements that I have set forth in this application are true and correct to the best of my knowledge. I understand that any omission or misrepresentation by me in this application are cause for possible cancellation of this application or, if employed, may be cause for dismissal, regardless of time of discovery. Any offer of employment is contingent upon completion of a successful background investigation. I further understand that if I am hired by Virginia Home Care Partners, I must agree, in writing, to comply with the Virginia Home Care Partners Employment Manual. Any employment resulting from this application will be employment at will. This means that an employee has the right to terminate their employment at any time for any reason, and the company may exercise the same right.All applicants for employment will be considered without regard to race, religion, color, national origin, sex, marital status, pregnancy status, age, disability, veteran status, sexual orientation, or sexual affectation. I (Applicant) hereby authorize Virginia Home Care Partners to request and receive from all prior employers, within 3 years of the date of this application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination. I hereby release said companies, organizations, agents, individuals, and Virginia Home Care Partners from any liability for any damage whatsoever resulting from the giving of such information. By checking here I agree to the above Certification and Agreement * Agree If you are human, leave this field blank. Submit Δ
