COMMUNITY VISITING NURSE ASSOCIATION

APPLICATION FOR EMPLOYMENT

Community Visiting Nurse Association is an equal opportunity employer and does not unlawfully discriminate in employment as to any protected category, including but not limited to race, color, religion, national origin, age, mental status, sex, physical and mental handicap or disability, or any other protected status.

Last Name:		Today's Date:
First Name:	Middle:	Maiden Name:
Street:	Apt#:	Telephone:
City:	State: Zip Code:
Soc. Sec.#:

Position Applied For:

Home Health Aide	RN	LPN	PT
Public Health Nurse	OT	ST	Administrative Staff
Nutritionist	Other:

Salary Desired: Type of position looking for (P/D, P/T, F/T):

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: expiration date:
If RN, LPN or therapist, give registration#: and state: exp. date:
Do you have professional (malpractice) insurance? Yes No
If yes input the insurance company and policy# :
Skill (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 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:

Have you even been convicted of a crime? Yes No

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.)

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 known

Previous Employers (Start with most recent/current position)

Name		Address
From	To	City	State	Phone
Position	Supervisor	Salary	Reason for leaving

Name		Address
From	To	City	State	Phone
Position	Supervisor	Salary	Reason for leaving

Name		Address
From	To	City	State	Phone
Position	Supervisor	Salary	Reason for leaving

Name		Address
From	To	City	State	Phone
Position	Supervisor	Salary	Reason for leaving

By checking this box I certify that the information 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 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