Community Visiting Nurse Association of Somerset County, Middlesex County VNA, Hospice & Home Care

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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:
	Email:

Position Applied For:

RN	LPN	PT	OT
SLP	CHHA	Nutritionist	Administrative Staff
Other:

Salary Desired:

How did you hear about the position:

Education	Name of School	City and State	Completed Yes/No
High School
College
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? Yes No
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? Yes No
Drivers License #: State:

Do you have the legal right to work in the U.S.? Yes No

Are you 18 years of age? Yes No

Are you employed now? Yes No If so, what hours?

May we inquire of your present employer ? Yes No

Can you work	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
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? Yes No

If yes, indicate name, relationship and when?

Have you ever applied for employment with Community Visiting Nurse Association ? Yes No

If yes, when?

Have you ever been discharged from a job or forced/asked to resign ? Yes No

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? Yes No

If yes, please explain and suggest any reasonable accommodation:

PERSONAL/PROFESSIONAL REFERENCES

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/ Relationship	Years Aquainted

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.

Attached is a copy of my resume file

Or mail a paper copy of your resume to:

Community Visiting Nurse Association
110 West End Avenue
Somerville, NJ 08876
Attn. Human Resources