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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.
DATE:
Last Name:*
First Name:*
Middle Initial:
Best Number to call you:*
Street Address:
City:
State:
Zip Code:
Cell Telephone Number:
Other Names under which you were employed:
Social Security Number:
Position Applying for:*
Specify type of work desired:
Specify days and hours willing to work:*
Minimum acceptable rate/salary:
How did you find out about us?*
When can you begin to work?
Are you available to work weekends?
If referred, please enter the persons full name:
E-MAIL ADDRESS (REQUIRED):*
Whom should we contact in case of emergency?
Name:*
Address:
Telephone:*
Relation:
City, State, Zip:
Are you a US Citizen or Authorized to work in the United States?
- Yes
- No
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
School/Training 1*
Dates Attended 1*
*
- Yes
- No
*
School/Training 2
Dates Attended 2
- Yes
- No
School/Training 3
Dates Attended 3
- Yes
- No
School/Training 4
Dates Attended 4
- Yes
- No
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
State 1
License 1
Original issue 1
Date renewal 1
Expiration date 1
2
State 2
License 2
Original issue 2
Date renewal 2
Expiration date 2
3
State 3
License 3
Original issue 3
Date renewal 3
Expiration date 3
4
State 4
License 4
Original issue 4
Date renewal 4
Expiration date 4
Employment History
Dates of employment
Employer's Name 1*
Telephone Number 1*
Starting Salary 1*
Ending Salary 1*
Month
Year
Employer's Address 1*
Title and Duties 1*
From
From month*
From Year*
Supervisor's Name/Title*
Telephone Number*
To
To month*
To Year*
Reason for Leaving 1*
Status*
- FT
- PT
Hours Weekly*
Dates of employment
Employer's Name 2
Telephone Number 2
Starting Salary 2
Ending Salary 2
Month
Year
Employer's Address 2
Title and Duties 2
From
From month 2
From Year 2
Supervisor's Name/Title 2
Supervisor's Name/Title 3
Telephone Number
Telephone Number
To
To month 2
To Year 2
Reason for Leaving 2
Status 2
- FT
- PT
Hours Weekly
Dates of employment
Employer's Name 3
Telephone Number 3
Starting Salary 3
Ending Salary 3
Month
Year
Employer's Address 3
Title and Duties 3
From
To
From month 3
To month 3
To Year 3
To Year 3-1
Reason for Leaving 3
Status 3
- FT
- PT
Hours Weekly
May we communicate with your employers?
Past?
- Yes
- No
Present?
- Yes
- No
Information provided in response to these questions will not necessarily bar employment If answer to questions 1, 2, 6, or 8 is "YES" please give full details on separate sheet.
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?
1. Has your clinical license to practice in any jurisdiction ever been limited, suspended or revoked?*
- Yes
- No
2. Has your clinical privileges ever been suspended, diminished, revoked or not renewed?*
- Yes
- No
3. Do you have the ability to perform all essential job functions?
- Yes
- No
4. Do you have any relatives employed at this agency?
- Yes
- No
5. Have you ever applied for a position or been employed before at VISITING NURSE GROUP, INC.
- Yes
- No
6. If hired, will you consent to a physical examination at any time scheduled by your supervisor?
- Yes
- No
7. Were you in the United States Armed Forces?
- Yes
- No
8. Have you ever missed work for more than five days?*
- Yes
- No
9. Are you able to stand for long periods of time?
- Yes
- No
10. Are you trach and vent certified? (LPN's only)
- Yes
- No
11. Do you have a cell phone? If not how do you intend to communicate with the office staff?
- Yes
- No
12. Do you have a valid driver's license?
- Yes
- No
13. Do you have reliable, insured transportation?
- Yes
- No
14. Are you willing to drive up to 50 miles?
- Yes
- No
1. Has your clinical license to practice in any jurisdiction ever been limited, suspended or revoked? (N/A)
2. Has your clinical privileges ever been suspended, diminished, revoked or not renewed? (N/A)
3. Do you have the ability to perform all essential job functions? (N/A)
4. Do you have any relatives employed at this agency? (N/A)
5. Have you ever applied for a position or been employed before at VISITING NURSE GROUP, INC. (N/A)
6. If hired, will you consent to a physical examination at any time scheduled by your supervisor? (N/A)
7. Were you in the United States Armed Forces? (N/A)
8. Have you ever missed work for more than five days? (N/A)
9. Are you able to stand for long periods of time? (N/A)
10. Are you trach and vent certified? (Nurses only) (N/A)
11. Do you have a cell phone? If not how do you intend to communicate with the office staff? (N/A)
12. Do you have a valid driver's license? (N/A)
13. Do you have reliable, insured transportation? (N/A)
14. Are you willing to drive up to 50 miles? (N/A)
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.
Resume
Max. file size: 32 MB.
Photo I.D.
Max. file size: 32 MB.
Professional License or Certifications
Max. file size: 32 MB.
CPR Certification
Max. file size: 32 MB.
Professional Liability Insurance (for Nurses)
Max. file size: 32 MB.
Social Security Card
Max. file size: 32 MB.
Car Insurance Card
Max. file size: 32 MB.
Car Registration (If applicable)
Max. file size: 32 MB.
Current Physical Examination
Max. file size: 32 MB.
TB Test or Chest X-ray
Max. file size: 32 MB.
Hepatitis B Vaccination
Max. file size: 32 MB.
Rubella/Rubeola Vaccination or Screening Test (Blood Test)
Max. file size: 32 MB.
Complete the Medical History Form provided by the Agency
Max. file size: 32 MB.