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Employment Application

All fields with an * MUST be completed. No application will be accepted without these fields completed.

Personal Data

First Name:*		Last Name:*	MI
Address:*		City:*	State:*
		Zip:*	Email:*
Home Phone:*		SS#:*
Work Phone:*		May we contact you at work?*
	Are you either 18 years of age or in possession of a work permit under the child labor laws?*
	Are you legally eligible to work in the United States? (Proof of eligibility will be required upon offer of employment)

	Are you a former employee?*	If yes, please specify:	to
	Have you filed an application with us before?*	If yes, please specify:	to

How did you hear about us?*

Specify:

Type Of Employment Desired*

Full Time

Part Time

Per Diem

Temporary

Summer Dates available from

Position Desired #1*

Position Desired #2

What salary or rate do you expect to receive if employed?*

$ Per

If you were selected for employment, what date would you be available to start?*

For those applicants applying for any position that requires driving as part of their job responsibilities, please answer the following questions.

Do you have:

A Car?*		A valid drivers license?*
Automobile Insurance?*

Employment Questionnaire

Have you ever been convicted or pled guilty to any moving violations in the past five years? If yes, explain.*

Have you been convicted (including any guilty plea which resulted in a final conviction) of a crime, other than a traffic violation, which has not been expunged or sealed by a court?*

If yes, describe fully the criminal conviction(s), listing the nature of the offense, and your rehabilitation since the conviction(s). (A conviction record will not necessarily be a bar to employment.)

*Have you volunteered your time for any organizations, e.g. Red Cross? If yes, where?*

Briefly describe your duties and skill acquired through volunteer service (including dates).

*You are not required to list any information which would tend to reveal a protected characteristic as set forth in the previous EEO statement.

Please identify and explain any gaps in employment longer than three months

Check skills/equipment operated:

Lotus 1-2-3	Windows 2000/XP	Steno
Switchboard	Excel	Powerpoint
Calculator	Word	Typewriter/WPM
Dictaphone	Fax

Employment History 1

Employer:			May we contact at present time?
Address:

City:
State:		Zip:
Telephone:
Employment Dates:	to
Last Position:
Starting Position:
Salary:
Brief description of duties:

Reason for leaving:

Employment History 2

Employer:			May we contact at present time?
Address:

City:
State:		Zip:
Telephone:
Employment Dates:	to
Last Position:
Starting Position:
Salary:
Brief description of duties:

Reason for leaving:

Employment History 3

Employer:			May we contact at present time?
Address:

City:
State:		Zip:
Telephone:
Employment Dates:	to
Last Position:
Starting Position:
Salary:
Brief description of duties:

Reason for leaving:

Education
High School Name:
Address:

City:
State:		Zip:
Course of study/major:		Years Completed:
Did you graduate?
List Diploma or Degree:

College Name:
Address:

City:
State:		Zip:
Course of study/major:		Years Completed:
Did you graduate?
List Degree:

Graduate College Name:
Address:

City:
State:		Zip:
Course of study/major:		Years Completed:
Did you graduate?
List Degree:

Professional Licenses and/or Certifications
Are you currently:	Registered	Licensed	Certified
Are you eligible for:	Registration	Licensure	Certification

If Licensed, Registered or Certified:
Type:
State Issued:
Date:
Number:
Has your license ever been under review because of the activity related to patient care or the performance of your duties in your profession?

Has your license ever been revoked or suspended because of activity related to patient care or the performance of your duties in your profession?

Resume
If you have a resume file, please attach it. Only pdf or doc files please.

Applicant's Statement - PLEASE READ CAREFULLY

It is my understanding that VNANNJ is an equal opportunity employer and that all qualified applicants will receive consideration without regard to race, color, religion, creed, national origin, ancestry, age, sex, physical or mental handicap or disability, veteran's status, sexual orientation, genetic make-up or any other legally protected status.

I understand that all offers of employment are conditioned by VNANNJ's receipt of satisfactory responses to reference requests and a background check. I authorize VNANNJ to investigate all statements contained in this employment application.

I also recognize that while my application will be given every consideration, its receipt by VNANNJ does not imply that I will be employed. Further, I acknowledge that any offer of employment is contingent upon my satisfactorily completing the pre-placement medical examination and/or inquiry. I understand that failure to cooperate with the pre-placement medical examination and/or inquiry may result in withdrawal of any employment offer. I also recognize that, if I receive an offer of employment, it may be revoked if it is determined that I cannot perform the essential job functions of the position with or without a reasonable accommodation, or if providing a reasonable accommodation would impose an undue hardship to the organization, or if my employment would pose a direct threat of substantial harm to myself or others.

If hired, I agree to abide by all of VNANNJ's rules and regulations, and understand that, if employed, both during and subsequent to my introductory period, I will be an employee at-will, which means that I can voluntarily end my employment or be terminated at any time without cause or notice.

I understand no statement, whether written or oral, by any VNANNJ representative other than a written statement signed by the Chief Executive Officer may vary the foregoing.

I understand that any falsification, misstatement, omission or misleading information given in my application or interview or in connection with VNANNJ records may result in the rejection of my application, the withdrawal of any offer of employment or my dismissal, regardless of the timing or circumstances. I hereby certify that all of the information provided by me in this application (or any other required document(s)) is correct, accurate and complete to the best of my knowledge.

I agree*

The Visiting Nurse Association of Northern New Jersey, Inc. is an equal opportunity employer. All qualified applicants will receive consideration without regard to race, color, religion, creed, national origin, ancestry, age, sex, physical or mental handicap or disability, veteran's status, sexual orientation, genetic make-up or any other legally protected status.

VNANNJ will make reasonable accommodations to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation would impose an undue hardship on the operation of our organization.

Visiting Nurse Association
of Northern New Jersey, Inc.
175 South Street - Morristown, New Jersey 07960 - (973) 539-1216

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