Application for Employment
Community Visiting Nurse Association is an equal opportunity employer and will not discriminate in employment as to any protected category, including but not limited to race, religion, age, gender, sexual orientation, disability (mental or physical), communicable disease or place of national origin, or any other protected status.
Application For Employment
Last Name: Today's Date:
First Name: Middle: Other names used:
Street: Apt#: Telephone:
City: State: Zip Code:
Position Applied For:
SLP CHHA Nutritionist Administrative Staff
Salary Desired: How did you hear about the position:
Education Name of School City and State Completed
High School
Nursing School

Subjects of special study or research work:

If HHA or CNA give
certificate#: and state: exp. date:
If RN, LPN or therapist give
license#: and state: exp. date:
Do you have professional (malpractice) insurance?
If yes what is the name of the insurance carrier and policy #:
Skills (i.e. CPR, IV Certifications, etc.):
Do you have a current driver's license?     
Drivers License #: State:
Do you have the legal right to work in the U.S.?
Are you 18 years of age?
Are you employed now?    If so, what hours?
May we inquire of your present employer ?
Can you work






the following: Full days Part days AM PM Nights  
Specify hours you can work: Date available:
Do you have any relatives working for Community Visiting Nurse Association or its affiliates?
If yes, indicate name, relationship and when?
Have you ever applied for employment with Community Visiting Nurse Association ?
If yes, when?
Have you ever been discharged from a job or forced/asked to resign ?
If yes, describe in full:
Is there any reason known to you why you could not consistently meet the essential duties of the job with or without reasonable accommodation?
If yes, please explain and suggest any reasonable accommodation:
Have you even been convicted of a crime?
If yes, please describe in full:
(A "yes" answer will not be an automatic bar to employment. Your case will be judged on its own merits.)
Give below the names of three (3) persons, not former employees or relatives, whom you have known at least one (1) year.
Full Name Address Telephone# Business/
Previous Employers (Start with most recent/current position)
Name: Address:
From: To: City: State: Phone:
Your Position: Supervisor: Salary: Reason for leaving:
Name: Address:
From: To: City: State: Phone:
Your Position: Supervisor: Salary: Reason for leaving:
Name: Address:
From: To: City: State: Phone:
Your Position: Supervisor: Salary: Reason for leaving:
Name: Address:
From: To: City: State: Phone:
Your Position: Supervisor: Salary: Reason for leaving:
By checking this box
I certify that the information contained in this application is true and complete to the best of my knowledge and belief. I understand that any misrepresentation or omission of fact in this application will be cause for refusal of employment, or if employed, termination from the company. I______________________________, hereby authorize Community Visiting Nurse Association to request and receive from all prior employers within one year of the date of application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination. I authorize Community Visiting Nurse Association, its agents and/or representatives, to investigate me, my education and my past employment fully. In consideration of my employment, I agree to comply with the policies, rules, regulations and procedures of the Company. I understand that I do not have a Contract of Employment with the Company, that my employment will be at-will and is not for a definite duration and that my employment can be terminated with or without cause or notice at any time, at the option of either the Company or myself.

       Signature                      Date
Or mail a paper copy of your resume to:
Community Visiting Nurse Association
110 West End Avenue
Somerville, NJ 08876
Attn. Human Resources