VNANW Application

Application For Employment

VNA Northwest, Inc. is an equal opportunity employer. As set forth under State and Federal Law, VNA Northwest, Inc. will not discriminate, except in the case of a bona fide occupational qualification or need, on the basis of race, color, religious creed, age, sex, marital status, sexual orientation, national origin, ancestry, present or past history of mental disability, mental retardation, learning disability, or physical disability with respect to hiring, compensation, promotion, discharge, or other terms and conditions of employment.

This is a secure online employment application. We take great care to protect the information you supply on this site by encrypting it.

All required fields are denoted by a red asterick ( * )

Position Desired

Salary Desired

(If applicable a copy of current license/certification will be required upon employment)

Social Security #

* ex. 123-45-6789

Name

Street Address

City, State Zip

Telephone

IF YOU HAVE LIVED AT ABOVE ADDRESS LESS THAN 12 MONTHS, LIST PREVIOUS ADDRESS

Street Address

City, State Zip

ARE YOU LEGALLY AUTHORIZED TO ACCEPT EMPLOYMENT IN THIS COUNTRY?

Yes No (Proof of eligibility required upon employment.)

IF EMPLOYED, AND YOU ARE UNDER 18, CAN YOU FURNISH A WORK PERMIT?

Yes No

DO YOU HAVE ADEQUATE MEANS OF TRANSPORTATION TO GET TO WORK ON TIME EACH DAY AND WHEN CALLED IN ON SHORT NOTICE?

Yes No

HAVE YOU EVER BEEN CONVICTED OF ANY CRIMINAL OFFENSE OTHER THAN TRAFFIC VIOLATIONS?

Yes No

You are not required to disclose an arrest, criminal charge or conviction if the records have been erased under Conn. Gen. Stat. Sections 46b-146, 54-76o, or 54-142a. Records subject to such erasure are records pertaining to a delinquency or that a child was a member of a family with service needs, youthful offenders, dismissed or nolled criminal charges, not guilty adjudications, or absolute pardons. Any person whose criminal records have been erased is deemed never to have been arrested and may swear so under oath.

IF YES, GIVE DATE, LOCATION, AND TYPE OF CONVICTION?

HAVE YOU SERVED IN THE MILITARY?

Yes No

IF YES, STATE THE TYPE OF MILITARY DISCHARGE RECEIVED?

LIST THE DATE YOU CAN BEGIN WORK

Date

ARE YOU AVAILABLE TO WORK FIRST SHIFT (8:30 am - 4:30pm)?

Yes No

YOU MAY BE REQUIRED TO WORK OVERTIME AS VNA NORTHWEST, INC. DETERMINES NECESSARY. WILL YOU WORK OVERTIME WHENEVER SCHEDULED OR REQUESTED?

Yes No

IF NO, PLEASE EXPLAIN

YOU MAY BE REQUIRED TO WORK WEEKENDS AND/OR HOLIDAYS AS VNA NORTHWEST, INC. DETERMINES NECESSARY. WILL YOU WORK WEEKENDS AND/OR HOLIDAYS WHENEVER SCHEDULED OR REQUESTED?

Yes No

IF NO, PLEASE EXPLAIN

IS THERE ANY REASON YOU CANNOT PERFORM THE DUTIES AND RESPONSIBILITIES OF THE POSITION FOR WHICH YOU ARE APPLYING?

Yes No

IF YES, PLEASE EXPLAIN

WOULD YOU ACCEPT PART-TIME WORK?

Yes No

WOULD YOU ACCEPT TEMPORARY WORK?

Yes No

PLEASE LIST ANY OTHER SKILLS YOU POSSESS

IF APPLYING FOR AN OFFICE POSITION

Typing - WPM

PLEASE LIST THE NAMES OF THE COMPUTER PROGRAMS YOU ARE FAMILIAR WITH

Word Processing

Spreadsheet

Accounting

Other

PLEASE LIST THE BUSINESS MACHINES YOU CAN OPERATE

PLEASE LIST YOUR LONG RANGE OCCUPATIONAL GOALS

DID YOU GRADUATE?

Yes No

IF YES, PLEASE LIST DEGREE RECEIVED

PLEASE LIST YOUR RELEVANT HIGH SCHOOL INFORMATION

School Name

School City State

Year Completed

(If not completed list current grade)

Relevant Subjects

PLEASE LIST YOUR RELEVANT COLLEGE INFORMATION

School Name

School City State

Major

Year Completed

(If not completed list current year)

Relevant Subjects

LIST ANY SPECIAL SCHOOLING OR TRAINING

LIST YOUR LICENSE INFORMATION

Professional Lic #

Exp Date

CPR Certification

Exp Date

LIST TRAINING, SKILLS OR EXPERIENCES YOU FEEL ARE APPLICABLE TO THE POSITION FOR WHICH YOU ARE APPLYING

(Amount of education considered necessary will vary according to job applied for)

EMPLOYMENT HISTORY

List all previous employers for whom you have worked during the last five years. Explain any lapses between times employed.

Company Name

City/State/Zip

Company Phone

Dates To/From

Last Position

Last Salary

Reason For Leaving

Company Name

City/State/Zip

Company Phone

Dates To/From

Last Position

Last Salary

Reason For Leaving

Company Name

City/State/Zip

Company Phone

Dates To/From

Last Position

Last Salary

Reason For Leaving

Company Name

City/State/Zip

Company Phone

Dates To/From

Last Position

Last Salary

Reason For Leaving

Company Name

City/State/Zip

Company Phone

Dates To/From

Last Position

Last Salary

Reason For Leaving

COMMENTS REGARDING LAPSES IN EMPLOYMENT (IF APPLICABLE)

HAVE YOU EVER BEEN DISCHARGED FROM A JOB OR FORCED OR ASKED TO RESIGN?

Yes No

MAKE ANY COMMENTS YOU FEEL WE SHOULD KNOW WHEN WE CONTACT YOUR PREVIOUS EMPLOYERS

PLEASE LIST THE NAMES AND CURRENT ADDRESS OF FOUR INDIVIDUALS (NOT RELATIVES OR EMPLOYEES) WHO CAN PROVIDE A PERSONAL REFERENCE.

* I also recognize that this application is not a contract of employment, nor should any of its terms be considered part of any employment contract. I understand that employment at VNA Northwest, Inc. is employment-at-will. I further understand that no VNA Northwest, Inc. employee or representative has authority to enter into a contract regarding my employment or in any way changing the at-will status of my employment except for the Executive Director of VNA Northwest, Inc. and then only by means of a signed written contract.

This is a secure online employment application. We take great care to protect the information you supply on this site by encrypting it.

Submit Application

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	VNA Northwest, Inc.
	607 Bantam Road Unit F P.O. Box 1867 Litchfield, CT. 06759-1867 E-mail: info@vnanw.org	TEL:(860) 567-6000 FAX:(860) 567-6012 Toll Free 1-800-752-0215
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VNA Northwest Inc. An Equal Opportunity Employer

VNA Northwest Inc.
An Equal Opportunity Employer