"This 'work' takes so little, and gives so much; both to me and to those we serve." - Medical Social Worker
Employment Form

Fields with * are REQUIRED.

*Position(s) Applied For:
 
other
 
Full time Shift Work Part time
Temporary Per Visit Other
*Salary Expectations:
How did you learn about us?  
*Last name:
*First name:
Middle Initial:
*Address line one:
Address line two:
*City: *State:
*Zip Code:
*E-mail:
*Cell Phone:
Home Phone: Work Phone:
Social Security Number:  
Are you currently employed?   Yes: No:
May we contact your present employer?   Yes: No:
What days are you available for work?  
What hours are you available for work?  
If applying for temporary work, during what period of time will you be available?  
From:
To:
Are you available for work on weekends?   Yes: No:
Would you be available to work overtime, if necessary?   Yes: No:
If hired, what date can you start work?   (yyyy-mm-dd)
Personal Information:
Have you ever applied to or worked for VNHC before?   Yes: No:
If yes, when?  
Do you have any friends or relatives working for VNHC?   Yes: No:
If yes, state name(s) and relationship:   Name:

Relationship:
If hired, would you have a reliable means of transportation to and from work?   Yes: No:
*Are you at least 18 years of age?
(If under 18, hire is subject to verification that you are of legal minimum age.)		   Yes: No:
Do you have any commitments to another employer that may affect your employment with us?   Yes: No:
If yes, please provide further information.  
*If hired, can you present evidence of your US citizenship or proof of your legal right to live and work in this country?   Yes: No:
Do you have any handicap or limitation on your ability to perform the duties of the job?   Yes: No:
If yes, describe the conditions and the nature of your work limitations (Note: Hire may be subject to passing a physical examination):  
Have you been convicted of a criminal offence?   Yes: No:
If yes, please briefly describe the circumstances of your conviction, indicating the date, nature and place of the offence and disposition of the case. Please state whether the crime was a misdemeanor or a felony. Applicant may omit any convictions for the possession of marijuana (except for the convictions for the possessions of marijuana on school grounds or possession of concentrated cannabis) that are more than (2) years old, and any information concerning a referral to, and participation in, any pretrial or post trial diversion program. A conviction will not necessarily disqualify you from employment. No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances, and the relevance of the offense to the position(s) applies for may be considered.) Do not include arrests without convictions, or convictions for misdemeanors for which you have successfully completed probation or were otherwise discharged.  
Why do you think you are qualified for this position?  
Education, Training, and Experience
High School Name/ Equivalent: Address: Years Completed:
Diploma: Yes No
 
  
Vocational School Name/Equivalent: Address: Years Completed:
Major: Diploma/Degree/Certificate:  
Health Care (special courses): Name & Address: Years Completed:
Major: Diploma/Degree/Certificate:
College/University: Address: Years Completed:
Major: Diploma/Degree/Certificate:
Graduate School: Address: Years Completed:
Major: Diploma/Degree/Certificate:  
Please indicate any foreign languages you can speak, read and/or write:
Language 1: Speak: Fluent: Fair: Poor:
    Read: Fluent: Fair: Poor:
    Write: Fluent: Fair: Poor:
Language 2: Speak: Fluent: Fair: Poor:
    Read: Fluent: Fair: Poor:
    Write: Fluent: Fair: Poor:
Language 3: Speak: Fluent: Fair: Poor:
    Read: Fluent: Fair: Poor:
    Write: Fluent: Fair: Poor:
Do you have any other experience, training, qualifications, or skills which you feel make you especially suited for work at the VNHC? If so, please explain:  
*Are you licensed/certified for the job you are
applying for?		   Yes: No: N/A:
Name of license/certificate (if not applicable please type N/A):  
Issuing State:  
License/certification number:  
Has your license/certificate ever been revoked or suspended?   Yes: No:
If yes, please state reason(s), date of revocation, or suspension and date of reinstatement:  
List below three persons who have knowledge of your work performance within the last three years.
Reference 1
Last name: First name:
Relationship: Number of years acquainted:
Address line one: City:
Address line two: State:
Zip Code: Telephone:
Email: Occupation:
Reference 2
Last name: First name:
Relationship: Number of years acquainted:
Address line one: City:
Address line two: State:
Zip Code: Telephone:
Email: Occupation:
Reference 3
Last name: First name:
Relationship: Number of years acquainted:
Address line one: City:
Address line two: State:
Zip Code: Telephone:
Email: Occupation:

Employment Experience

Please complete the section below as thoroughly as possible. List all present and past employment (full or part time), including periods of unemployment. Start with your most recent employer, and go back at least 10 years. If this information is not available in your resume, please complete the information below.

Employer 1
Employer: Address:
Telephone Number(s): E-mail:
Supervisor Name: Supervisor Phone:
Position/Job Title:    
Starting Salary: Per:
From: (yyyy-mm-dd) To: (yyyy-mm-dd)
Final Salary: Per:
Work Perfomed Reasons for Leaving:
Employer 2
Employer: Address:
Telephone Number(s): E-mail:
Supervisor Name:
Position/Job Title:
Starting Salary: Per:
From: (yyyy-mm-dd) To: (yyyy-mm-dd)
Final Salary: Per:
Work Perfomed Reasons for Leaving:
Employer 3
Employer: Address:
Telephone Number(s): E-mail:
Supervisor Name:
Position/Job Title:
Starting Salary: Per:
From: (yyyy-mm-dd) To: (yyyy-mm-dd)
Final Salary: Per:
Work Perfomed Reasons for Leaving:
Employer 4
Employer: Address:
Telephone Number(s): E-mail:
Supervisor Name:
Position/Job Title:
Starting Salary: Per:
From: (yyyy-mm-dd) To: (yyyy-mm-dd)
Final Salary: Per:
Work Perfomed Reasons for Leaving:

If you need additional space, please continue in the space below

Special Skills and Qualifications

Summarize special skills and qualifications acquired from employment or other experience:

PLEASE READ BELOW AND ACKNOWLEDGE THAT YOU HAVE READ AND AGREE TO THE TERMS STATED

"I certify that the information provided in this application is true and complete to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any falsification, omission, misrepresentation or concealment of information on this application, during interviews, or at any other time during the hiring process may result in rejection of this application or, if hired, may result in discipline up to and including dismissal, regardless of the time elapsed before discovery.

I hereby authorize Visiting Nurse & Hospice Care of Santa Barbara to thoroughly investigate my references, work records, and other matters related to my suitability for employment and, further, authorize my former and current employers to disclose to the company any and all letters, reports and other information related to my work history. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I understand that nothing contained in the application or conveyed during any interview which may be granted is intended to create an employment contract between me and Visiting Nurse & Hospice Care. I also understand that all offers of employment are conditional upon satisfactory reference checks, completion of Visiting Nurse & Hospice Care's standard confidentiality agreement and production of documents necessary for Visiting Nurse & Hospice Care to verify identity and work authorization in accordance with the USCIS form I-9. I also understand that a company paid drug test and/or physical examination and background and/or credit check may be required and if performed, employment would be contingent upon satisfactory results. I also authorize Visiting Nurse & Hospice Care to conduct any of the foregoing.

I understand and agree that my employment is at-will and I may terminate my employment at any time without cause or notice; similarly, my employment may be terminated or my status changed (for example, my position may be changed, I may be demoted, or my benefits may be changed) by the Company at any time without cause or notice. I also understand that this at-will agreement will remain in effect throughout the duration of my employment and may only be changed by a written agreement signed by the President/CEO of Visiting Nurse & Hospice Care.

I have read above terms and agree to them: Yes: No:

Voluntary Survey
Check One: Male Female

Check One Of The Following (Ethnic Origin)

Hispanic or Latino
White, not Hispanic or Latino
Black or African American, not Hispanic or Latino
Native Hawaiian or Other Pacific Islander, not Hispanic or Latino
Asian, not Hispanic or Latino
American Indian or Alaskan Native, not Hispanic or Latino
Two or more races, not Hispanic or Latino

Check If Any Of the Following Are Applicable

Vietnam Era Veteran Disabled Veteran Not a Veteran  

To find out more on JOB OPPORTUNITIES at VNHC, please call us at 805-965-5555 in Santa Barbara and 805-693-5555 in Santa Ynez and Lompoc Valleys or click here