VNA of Rhode Island-Application

VNA of Rhode Island/VNA Support Services Employment Application 622 George Washington Hwy. Lincoln, RI 02865 (401) 335-2400 VNA of RI and VNASS are SMOKE FREE Environments
Position Applying For:
First Name:	MI:
Last Name:
Address:
City:	State:
Zip:

Social Security Number:
Home Phone:
Work Phone:	May we contact you at work?
Are you a citizen of the U.S. or Alien authorized to work in the United States?
Are you at least 18 years old?

Availability:	Full Time Part-time Per Diem

Education:	List current or most recent first
School Name and Address		Course Of Study	Did You Graduate?	Degree/Diploma




Professional Licenses/Certificates
Are you currently:	Registered Licensed Certified State Number
Are you currently:	Registered Licensed Certified State Number

List other training and skills you posses:

Employment History: List current or most recent first
1) Present or most recent employer
Company Name: Position Title:
Address: Date of Employment: to
Supervisor: May we contact?
Duties:
Reason for leaving:
2) Previous Employer
Company Name: Position Title:
Address: Date of Employment: to
Supervisor: May we contact?
Duties:
Reason for leaving:
3) Previous Employer
Company Name: Position Title:
Address: Date of Employment: to
Supervisor: May we contact?
Duties:
Reason for leaving:

Ø Can you perform the essential functions of the position for which you are applying?
Ø Do you have a RI driver’s license?
Ø Do you have a car available for travel?
Ø Can you provide proof of auto insurance?
Ø Rhode Island law requires employees of home health agencies be subject to a criminal background check. Would you be opposed to such a check? Have you had such a check within the last 18 months?
(Background Check Disqualifying information does not necessarily exclude one from employment.)

Ø Has any action ever been taken on your professional license in any state?
Ø Has any action ever been taken involving your clinical privileges (including voluntary suspension and non-renewal) in any state?
Ø Has professional liability insurance ever been denied or cancelled?
Ø Have any professional liability claims ever been made against you?
Ø Are you currently, or have you ever been, or has the government proposed that you be, excluded from participation in federal health care programs (e.g., Medicare, Medicaid)? If yes, please describe the circumstances and indicate the period of the exclusion:
Ø By what source did you come to apply?

References: List 3 References who can evaluate your work. Also, list how they are known to you.

PLEASE DO NOT LIST ANYONE RELATED TO YOU.
Name	How do you know them?		Address

Telephone:
Name	How do you know them?		Address

Telephone:
Name	How do you know them?		Address

Telephone:

Were you ever previously employed by VNA of Rhode Island, or VNA Support Services?
Have any of your friends or relatives worked here or are working here?
If yes give name and relationship:

	Résumé To cut and paste your résumé: 1. Highlight the text on the résumé you want to copy. 2. Press 'Ctrl C' to copy (Hold down the Ctrl key and press C). 3. Place the cursor in the RÉSUMÉ box below. 4. Press 'Ctrl V' to paste the information.
Résumé



I hereby affirm that the information given on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions may disqualify me from further consideration for employment and may result in discharge if discovered at a later date. If I am released under these conditions, I will be paid only through the day of release and my employer has the right to cancel any benefits that I may have accrued. I understand that acceptance of an offer of employment does not create a contractual obligation to continue to employ me in the future. My typed name below shall have the same force and effect as my written signature.
Candidate's/Applicant's Signature:
Date:

It is the policy of VNA of Rhode Island/VNA Support Services to check references offered by applicants. It is our objective to obtain information on ability, previous job performances, character and reputation for the sole purpose of considering you for employment. I hereby give VNA of Rhode Island/VNA Support Services permission to request and obtain any such information that will assist in becoming employed. My typed name below shall have the same force and effect as my written signature.
Candidate's/Applicant's Signature:
Date: Equal Employment Opportunity Identification The policy of the VNA of Rhode Island is to provide equal employment opportunity to all employees and applicants without regard to race, gender, color, religion, national origin, age, sexual orientation, disability, veteran status or gender. We are requesting that you provide the following information. Submission of this information is voluntary and refusal to provide it will not affect your chances of being selected for a position at the VNA of Rhode Island. This information will only be used by Human Resources for monitoring and reporting purposes and will be maintained in a confidential file separate from your application for employment. Gender: Ethnicity: Veteran Status: Ethnic Groups American Indian or Alaska Native A person having origins in any of the original peoples of North America and who maintains cultural identification Tribal affiliation or community recognition. Asian or Pacific Islander A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example: China, India, Japan, Korea, the Philippine Islands and Samoa. Black/African American A person having origins in any of the Black racial groups of Africa. Hispanic A person of Mexican, Puerto Rican, Central or South American culture or other Spanish culture or origin regardless of race. White A person having origins in any of the original peoples of Europe, North Africa or the Middle East.

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