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Job Application SSN Must be Supplied if Interviewed
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Indicates required field
First Name
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Middle Name
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Last Name
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Address
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Address2
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City
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State
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Zip Code
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Telephone Number
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Alternate Telephone Number
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Email
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Shift Preference
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Shifts Able to Work
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Expected Rate of Pay
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Type of Employment
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Full Time
Part Time
As Needed
Date Available
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Are You Over the Age of 18?
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Yes
No
If No, Employment is subject to verification that you are of minimum legal age.
Position Apply For:
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C.N.A.
N.A.
DCA
RMA (Must have Certification)
Cook/Dietary
House Keeping
If applying for a nursing position you must provide nursing certifications.
Can you, after employment submit verification of legal right to work in the U.S.?
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Yes
No
Have you ever worked for this facility?
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Yes
No
Have you ever applied for employment with us before?
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Yes
No
If so, when?
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Have you ever worked for a Valley Care Management facility?
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Yes
No
If yes, which one?
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Dogwood Crossing
Hawksbill
Journeys Crossing
Whispering Pines
MontVue Health Care
To your knowledge, are you related to any current employee?
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Yes
No
If yes, who?
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Do you understand that you be required to work holidays and/or weekends?Choose Any
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Yes
No
Have you ever been discharged or asked to resign from a position?
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Yes
No
If yes, explain
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Have you ever been convicted of a criminal offense?
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Yes
No
If yes, explain - DO NOT WRITE "WILL EXPLAIN/DISCUSS AT INTERVIEW"
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Do you understand that any offer of employment is subject to the result of Criminal History Check and Random Drug Screening during employment?
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Yes
No
Education
High School Name
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College Name
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Other, Nursing, Trade, etc.
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Highest year of High School Completed
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1
2
3
4
High School course of study
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Highest year of college completed
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1
2
3
4
4+
College course of study
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Highest year of other education completed
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1
2
3
Other course of study
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Did you graduate high school
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Yes
No
Did you graduate college
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Yes
No
Did you graduate other
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Yes
No
List high school degree
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List college degree
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List other degree
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Where did you get your Nursing or DCA certification from?
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Where did you get your Registered Medication Aid training from?
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Medication Aid License Number
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C.N.A. License Number
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Are you CPR Certified?
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Yes, Current
No, Expired
Never Had
Are you First Aid Certified?
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Yes, Current
No, Expired
Never Had
Employment Record - List below beginning with your most recent, all present and past employment.
Employer
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Telephone
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Dates
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Pay Rate
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Work Type
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Reason for Leaving
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Supervisor
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Employer
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Telephone
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Dates
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Pay Rate
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Work Type
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Reason for Leaving
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Supervisor
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Employer
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Telephone
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Dates
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Pay Rate
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Work Type
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Reason for Leaving
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Supervisor
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May we contact your present employer?
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Yes
No
Personal References (Not current employers or relatives)
Name
*
Occupation
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How do you know them?
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How long have you known them?
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Telephone
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Name
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Occupation
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How do you know them?
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How long have you known them?
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Telephone
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Job applicant's agreement, certification and release of information.
"The facts set forth above in my application for employment are true and complete; I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal if and when discovered." " I hereby irrevocably appoint any officer or administrator of Valley Care Management as my agent with full authority to request, inspect, copy and otherwise have access to the following on my behalf and in my stead to the extent that such information may relate to my past, present or future employment. "
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
All personal information and records now or hereafter maintained by any agency of the State of Virginia or the United States in any exiting or future information system with in the meaning of the Federal Privacy Act of 1974 and the Virginia Privacy Act of 1976 as the same may be amended from time to time.
All official records maintained by any agency or public body of the State of Virginia or the United States within the meaning of the Federal and Virginia Freedom of Information Act, as the same may be amended from time to time.
All records maintained by my present or past employers relating to my employment.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I agree to be employed on a 90 calendar days probationary period and that during this time I may be released of I may resign without any bad effect on my employment record. I agree to submit to a physical exam and drug screen whenever requested and, if employed, I agree to abide by all present and subsequently issued personnel policies and rules of Valley Care Management. In the event of employment, I understand that my employment is terminable at will for any reason.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Valley Care Management is an equal opportunity employer and does not discriminate on the basis of race, color, age, religion, sex, national origin, disability, veteran status, handicap or any other personal characteristic protected by Federal, State or Local Law. Applicants are not required to disclose information about physical or mental disabilities that will interfere with job performance. However they may suggest for consideration by Valley Care Management any special accommodations they believe would be appropriate to accommodate a physical or mental disability.
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