Application for Employment

The Visiting Nurse Association of Erie County is an equal opportunity employer which does not discriminate in employment practices based on individual’s race, color, citizenship status, national origin, ancestry, gender, age, religion, creed, physical or mental disability, sexual orientation, marital status, veteran status, political affiliation, any other legally protected characteristic, or for engaging in protected activities; nor is any question on this application asked for the purposes of limiting or excluding any applicant’s consideration for employment for these reasons.



PERSONAL RECORD
Name
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail
EDUCATION
High School Name
Location (City/State)

Last Year Completed:
Did You Graduate?
Major or Specialty
List Abilities, Activities,
Honors, Hobbies

COLLEGE

College Name
Location (City/State)
Last Year Completed
Did You Graduate?
Major or Specialty
List Abilities, Activities,
Honors, Hobbies
TRADE SCHOOL
Trade School Name
Location (City/State)
Last Year Completed
Did You Graduate?
Major or Specialty
List Abilities, Activities,
Honors, Hobbies
Do you have any special activities which start late in the summer, such as football or soccer practice, college orientation, etc.?
If so, list and give approximate starting dates
PAST EMPLOYMENT REFERENCES
Reference 1
Dates:   From
To
Name
Address
Telephone Number
Job Title
Supervisor
Pay Rate
Reason for Leaving
Reference 2
Dates:   From
To
Name
Address
Telephone Number
Job Title
Supervisor
Pay Rate
Reason for Leaving
Reference 3
Dates:   From
To
Name
Address
Telephone Number
Job Title
Supervisor
Pay Rate
Reason for Leaving
I can begin working full-time on
I can work full-time until
I am available weekends beginning:
I am unavailable weekends after:
I will attend school in the fall
If yes, where?
I can work:
Saturday
Sunday
Part-time
*NOTE: Your availability dates are very important. Please give serious considerations to the dates you choose because they will have a strong bearing on you application. Failure to comply with the dates you choose may affect future employment status.
A LITTLE ABOUT YOURSELF…
Are you employed elsewhere?
If so, where?
Do you have any special abilities, awards, hobbies?
Do you have a valid driver’s license?
Are you a U.S. Citizen or otherwise authorized to work in the U.S. on an unrestricted basis?
Are you fluent in a language other than English?
If so, which?
PAST MILITARY RECORD
Have you ever served in the Armed Forces of the United States?
If yes, date entered
If yes, date discharged
Reserves or National Guard status?
IN CASE OF AN EMERGENCY, WHO SHOULD WE NOTIFY?
Name
Phone
Relationship
Address:
JOB PREFERENCES
RN Case Manager
Per diem RN
Physical Therapist
Other
If other, please specify

Please note certain positions may have uniform requirements

Have you worked for us before?
Have you ever been excluded, suspended, or otherwise sanctioned by any federal or state health care program?
You may check my references
Additional Comments

I CERTIFY, by hitting ‘Submit Form,’ that this information is accurate and complete. Giving incomplete or false information for employment is a serious matter and is grounds for dismissal and forfeiture of related benefits.