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lock This is a secure online employment 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
*
Salary Desired
*
(If applicable a copy of current license/certification will be required upon employment)
   
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
ARE YOU LEGALLY AUTHORIZED TO ACCEPT EMPLOYMENT IN THIS COUNTRY?
Yes No     (Proof of eligibility required upon employment.)
 
IF EMPLOYED, AND YOU ARE UNDER 18, CAN YOU FURNISH A WORK PERMIT?
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
HAVE YOU SERVED IN THE MILITARY?
Yes No
IF YES, WERE YOU DISCHARGED FROM THE MILITARY UNDER OTHER THAN HONORABLE CONDITIONS?
LIST THE DATE YOU CAN BEGIN WORK
 
CLINICAL STAFF: ARE YOU AVAILABLE TO WORK EVENING ON-CALL ROTATION?
Yes No
YOU MAY BE REQUIRED TO WORK OVERTIME AS VNA NORTHWEST, INC. DETERMINES NECESSARY. WILL YOU WORK OVERTIME WHENEVER SCHEDULED OR REQUESTED?
Yes No
IF NO, PLEASE EXPLAIN
YOU MAY BE REQUIRED TO WORK WEEKENDS AND/OR HOLIDAYS AS VNA NORTHWEST, INC. DETERMINES NECESSARY. WILL YOU WORK WEEKENDS AND/OR HOLIDAYS WHENEVER SCHEDULED OR REQUESTED?
Yes No
IF NO, PLEASE EXPLAIN
ARE YOU ABLE TO PERFORM THE FUNCTIONS OF THE POSITION WITH OR WITHOUT REASONABLE ACCOMMODATION?
Yes No
IF YES, PLEASE EXPLAIN
WOULD YOU ACCEPT PART-TIME WORK?
Yes No
 
WOULD YOU ACCEPT TEMPORARY WORK?
Yes No
PLEASE LIST ANY OTHER SKILLS YOU POSSESS
IF APPLYING FOR AN OFFICE POSITION:
Typing - WPM
 
PLEASE LIST THE NAMES OF THE COMPUTER PROGRAMS YOU ARE FAMILIAR WITH
Word Processing
Spreadsheet
Accounting
Other
 
PLEASE LIST THE BUSINESS MACHINES YOU CAN OPERATE
PLEASE LIST YOUR LONG RANGE OCCUPATIONAL GOALS
DID YOU GRADUATE?
Yes No
IF YES, PLEASE LIST DEGREE RECEIVED
PLEASE LIST YOUR RELEVANT HIGH SCHOOL INFORMATION
School Name
School City State
Year Completed
     (If not completed list current grade)
Relevant Subjects
 
PLEASE LIST YOUR RELEVANT COLLEGE INFORMATION
School Name
School City State
Major
Year Completed
     (If not completed list current year)
Relevant Subjects
 
LIST ANY SPECIAL SCHOOLING OR TRAINING
LIST YOUR LICENSE INFORMATION
Professional Lic #
*        Exp Date  *
CPR Certification        Exp Date 
LIST TRAINING, SKILLS OR EXPERIENCES YOU FEEL ARE APPLICABLE TO THE POSITION FOR WHICH YOU ARE APPLYING
 
(Amount of education considered necessary will vary according to job applied for)
 
EMPLOYMENT HISTORY
List all previous employers for whom you have worked during the last five years. Explain any lapses between times employed.
 
Company Name
City/State/Zip
Company Phone
Dates To/From
Last Position
Last Salary
Reason For Leaving
 
Company Name
City/State/Zip
Company Phone
Dates To/From
Last Position
Last Salary
Reason For Leaving
 
Company Name
City/State/Zip
Company Phone
Dates To/From
Last Position
Last Salary
Reason For Leaving
 
Company Name
City/State/Zip
Company Phone
Dates To/From
Last Position
Last Salary
Reason For Leaving
 
Company Name
City/State/Zip
Company Phone
Dates To/From
Last Position
Last Salary
Reason For Leaving
 
COMMENTS REGARDING LAPSES IN EMPLOYMENT (IF APPLICABLE)
 
HAVE YOU EVER BEEN DISCHARGED FROM A JOB OR FORCED OR ASKED TO RESIGN?
Yes No
 
MAKE ANY COMMENTS YOU FEEL WE SHOULD KNOW WHEN WE CONTACT YOUR PREVIOUS EMPLOYERS
PLEASE LIST THE NAMES AND CURRENT ADDRESS OF FOUR INDIVIDUALS (NOT RELATIVES OR EMPLOYEES) WHO CAN PROVIDE A PERSONAL REFERENCE.
1.
2.
3.
4.
 
 
lock This is a secure online employment application. We take great care to protect the information you supply on this site by encrypting it.
 
 
 
 
 
 
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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