Application for Employment

  • VISITING NURSE GROUP, INC.

  • 128 West Girard Avenue, Philadelphia, PA 19123
    Office No. 215-829-8888 --- Fax No. 215-829-8875

  • APPLICATION FORM

  • VISITING NURSE GROUP, INC. IS AN EQUAL OPPORTUNITY EMPLOYER. WE COMPLY WITH ALL APPLICABLE LAWS OF THE STATE OF PENNSYLVANIA AND THE FEDERAL GOVERNMENT REGARDING EMPLOYMENT PRACTICES. THESE STATUTES PROHIBIT DISCRIMINATION IN EMPLOYMENT BASED ON RACE, CREED, COLOR, SEX, AGE, NATIONALITY ORIGIN, PHYSICAL OR MENTAL DISABILITY.

  • Whom should we contact in case of emergency?

  • NOTE: Verification of US Citizenship or US Employment will be required within three business days of the commencement of employment.

  • Please furnish all education and training which you believe qualifies you for the position you are seeking.

  • School/Training

  • Dates Attended

  • Graduated

  • Subjects Studied/Degree Awarded

  • Please complete if licensure/certification/registration is required for position you are seeking.

  • State

  • License/Certification Number

  • Date of original issue

  • Date of most recent renewal

  • Expiration date

  • 1
  • 2
  • 3
  • 4
  • Employment History

  • Dates of employment

  • Month

  • Year

  • From

  • To

  • Dates of employment

  • Month

  • Year

  • From

  • To

  • Dates of employment

  • Month

  • Year

  • From

  • To

  • May we communicate with your employers?

  • YES
  • NO
  • N/A
  • 1. Has your clinical license to practice in any jurisdiction ever been limited, suspended or revoked?
  • 2. Has your clinical privileges ever been suspended, diminished, revoked or not renewed?
  • 3. Do you have the ability to perform all essential job functions?
  • 4. Do you have any relatives employed at this agency?
  • 5. Have you ever applied for a position or been employed before at VISITING NURSE GROUP, INC ?
  • 6. If hired, will you consent to a physical examination at any time scheduled by your supervisor?
  • 7. Were you in the United States Armed Forces?
  • 8. Have you ever missed work for more than five days?
  • 9. Are you able to stand for long periods of time?
  • 10. Are you trach and vent certified? (Nurses only)
  • 11. Do you have a cell phone? If not how do you intend to communicate with the office staff?
  • 12. Do you have a valid driver's license?
  • 13. Do you have reliable, insured transportation?
  • 14. Are you willing to drive up to 50 miles?
  • PLEASE READ CAREFULLY
  • I certify that the statements made on this application are true and correct to the best of my knowledge and belief and hereby grant VISITING NURSE GROUP, INC. permission to verify such answers. I understand that any false statement on this application will be considered as sufficient cause for rejection of this application or for dismissal if such false statement is discovered subsequent to my employment. I authorize written access to any records concerning my education or employment background. I understand, that if, any inquiry is made, all information as to its nature and scope will be supplied upon written request. I will have to pass a post-employment physical examination, as a condition of employment. If this application is considered favorably, I agree to abide by and comply with all the employer's rules. Your ability to complete this application, clearly and effectively, will be considered a requirement for the job for which you are applying. As a policy of our agency, employees must have the ability to travel to client's homes throughout our service area. If traveling by automobile, current vehicle registration, automobile insurance and driver's license must be on file.