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Application for Independent Contract Caregivers
   
lock This is a secure online 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
*
  (If applicable, a copy of current licenses/certificates will be requested)
Name
*
Street Address
*
City, State Zip
*
Telephone
*
Email
*
IF YOU HAVE LIVED AT ABOVE ADDRESS LESS THAN 12 MONTHS, LIST PREVIOUS ADDRESS
Street Address
City, State Zip
VNA NorthWest Nursing Registry Inc. will need your Social Security Number prior to referrals.
 
ARE YOU LEGALLY AUTHORIZED TO ACCEPT EMPLOYMENT IN THIS COUNTRY?
Yes No     (Proof of eligibility required upon employment.)
 
DO YOU HAVE A VALID DRIVER'S LICENSE?
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
WOULD YOU BE WILLING TO USE YOUR CAR FOR CLIENT ERRANDS?
Yes No
 
WOULD YOU BE WILLING TO USE YOUR CAR FOR CLIENT TRANSPORTATION?
Yes No
 
HAVE YOU SERVED IN THE MILITARY?
Yes No
IF YES, WERE YOU DISCHARGED FROM THE MILITARY UNDER OTHER THAN HONORABLE CONDITIONS?
EDUCATION/TRAINING BACKGROUND
 
School Name
School City State
Year Completed
 
PLEASE LIST YOUR RELEVANT COLLEGE INFORMATION
School Name
School City State
Year Completed
DEGREE/s RECEIVED:
AREA OF CONCENTRATION:
 
CURRENT CREDENTIALS, IF APPLICABLE: RN LPN CNA
 
LIST YOUR LICENSE INFORMATION
Professional Lic #
*        Exp Date  *
HAVE YOU EVER HAD YOUR PROFESSIONAL LICENSE OR CERTIFICATION SUSPENDED, REVOKED, OR RESTRICTED?
Yes No
IF YES, PLEASE EXPLAIN
LIST TRAINING, SKILLS OR EXPERIENCES YOU FEEL ARE APPLICABLE TO THE POSITION FOR WHICH YOU ARE APPLYING
HAVE YOU EVER APPLIED TO THIS AGENCY IN THE PAST?
Yes No
 
HOW DID YOU HEAR ABOUT US?
ARE YOU CURRENTLY WORKING?
MAY WE CONTACT YOUR PRESENT WORKPLACE?
 
List below your work history, starting with the most recent employer.
Complete all information including full mailing address.
 
Company Name
City/State/Zip
Contact Name:
Company Phone
Dates To/From
Last Position
Last Salary
Reason For Leaving
 
Company Name
City/State/Zip
Contact Name:
Company Phone
Dates To/From
Last Position
Last Salary
Reason For Leaving
 
Company Name
City/State/Zip
Contact Name:
Company Phone
Dates To/From
Last Position
Last Salary
Reason For Leaving
 
COMMENTS REGARDING LAPSES IN EMPLOYMENT (IF APPLICABLE)
 
MAKE ANY COMMENTS YOU FEEL WE SHOULD KNOW WHEN WE CONTACT YOUR PREVIOUS EMPLOYERS
 
LIST WORK DONE AS AN INDEPENDENT CONTRACTOR OR OTHER TEMPORARY/REFERRAL/HOME HEALTH AGENCY WORK:
Date: From - To
Agency:
City/State
Role/Position
 
Date: From - To
Agency:
City/State
Role/Position
 
Date: From - To
Agency:
City/State
Role/Position
 
HAVE YOU EVER BEEN DISCHARGED FROM A JOB OR ASSIGNMENT?
Yes No
 
If YES, please explain:
 
PLEASE PROVIDE THREE (3) WORK-RELATED REFERENCES (those who have directly supervised you or who can attest to your work ethic from a professional perspective - no family, friends or co-workers). It is your responsibility to obtain permission from each of your references before providing us with their name, address and phone number.
Please complete all information including full mailing address.
Reference Name:
Reference Address:
Daytime Phone #:
Relationship/Business:
 
Reference Name:
Reference Address:
Daytime Phone #:
Relationship/Business:
 
Reference Name:
Reference Address:
Daytime Phone #:
Relationship/Business:
 
Are you able to perform the functions of the position with or without reasonable accommodation?
Yes No
 
If NO, please explain:
 
 
 
 
lock This is a secure online application. We take great care to protect the information you supply on this site by encrypting it.
 
 
Revised July 2014
 
 
 
Areas we serve:
Bantam, Barkhamsted, Bethlehem, Bridgewater, Cornwall, Colebrook, Falls Village, Goshen, Harwinton, Kent, Lakeville, Litchfield, Morris, New Hartford,
New Milford, New Preston, Norfolk, Northfield, North Canaan, Plymouth, Roxbury, Salisbury, Sharon, Terryville, Thomaston, Torrington,
Warren, Watertown, Washington, Washington Depot, West Cornwall, Winchester, Winsted, Woodbury