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VISITING NURSE GROUP, INC.

128 West Girard Avenue, Philadelphia, PA 19123

Office No. 215-829-8888 — Fax No. 215-829-8875 — www.visitingnursegroup.com

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 at:
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? Drive by Job Fair Internet Other			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? YesNo

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
		Yes	No
		Yes	No
		Yes	No
		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
2
3
4

Verified By:___________________   Date_____________________

Please Do Not Write In This Space — For Human Resources Use Only

Referred for Interview:				Date of Interview:
Department number/name:	Status:	Job Title:	Starting Salary:Starting Date:		Scheduled hours/shift:
Additional Comments:

References Sent:
1. Date Sent: __________ Rec’d:_______	Reviewed By: __________________________	Date: ____________
2. Date Sent: __________ Rec’d:_______

Employment History

Dates of employment			Employer’s Name		Telephone Number		Starting Salary	Ending Salary
	Month	Year	Employer’s Address			Title and Duties
From			Supervisor’s Name/Title	Telephone Number
To			Reason for Leaving				Status: FTPT	Hours Weekly

Dates of employment			Employer’s Name		Telephone Number		Starting Salary	Ending Salary
	Month	Year	Employer’s Address			Title and Duties
From			Supervisor’s Name/Title	Telephone Number
To			Reason for Leaving				Status: FTPT	Hours Weekly

Dates of employment			Employer’s Name		Telephone Number		Starting Salary	Ending Salary
	Month	Year	Employer’s Address			Title and Duties
From			Supervisor’s Name/Title	Telephone Number
To			Reason for Leaving				Status: FTPT	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 employm 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?

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.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, you 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.

Signature _______________________________________

Date _______________________