Erie VNA | Application for Employment

LECOM Health Visiting Nurse Association of Erie County

(814) 454-2831 1-800-441-6821 1-855-805-9620

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.

In addition to completing the application below, please also DOWNLOAD THE PERSONAL REFERENCE AND PRIOR EMPLOYMENT FORM. This form must be completed in full, signed, dated and returned to the Visiting Nurse Association of Erie County.

Application for Employment

PERSONAL RECORD
Name*
First Last
Title
Organization
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone
Home Phone
Fax
Email*
EDUCATION
High School Name
Location (City/State)
Last Year Completed
Did You Graduate?
- Yes
- No
Major or Specialty
Professional License #
PA Nurse Aide Registration #
List Abilities, Activities, Honors, Hobbies
COLLEGE
College Name
Location (City/State)
Last Year Completed
Did You Graduate?
- Yes
- No
Major or Specialty
List Abilities, Activities, Honors, Hobbies
TRADE SCHOOL
Trade School Name
Location (City/State)
Last Year Completed
Did You Graduate?
- Yes
- No
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
Date Format: MM slash DD slash YYYY
Dates: To
Date Format: MM slash DD slash YYYY
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Job Title
Supervisor
Pay Rate
Reason for Leaving
Reference 2
Dates: From
Date Format: MM slash DD slash YYYY
Dates: To
Date Format: MM slash DD slash YYYY
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Job Title
Supervisor
Pay Rate
Reason for Leaving
Reference 3
Dates: From
Date Format: MM slash DD slash YYYY
Dates: To
Date Format: MM slash DD slash YYYY
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Job Title
Supervisor
Pay Rate
Reason for Leaving
I can begin working full-time on
Date Format: MM slash DD slash YYYY
I can work full-time until
Date Format: MM slash DD slash YYYY
I am available weekends beginning
Date Format: MM slash DD slash YYYY
I am unavailable weekends after
Date Format: MM slash DD slash YYYY
I will attend school in the fall
- Yes
- No
If yes, where?
I can work
- Saturdays
- Sundays
- Part-time
*NOTE: Your availability dates are very important. Please give serious consideration to the dates you choose because they will have a strong bearing on your application. Failure to comply with the dates you choose may affect future employment status.
A LITTLE ABOUT YOURSELF…
Are you employed elsewhere?
- Yes
- No
If so, where?
Do you have any special abilities, awards, hobbies?
Do you have a valid driver’s license?
- Yes
- No
Are you a U.S. Citizen or otherwise authorized to work in the U.S. on an unrestricted basis?
- Yes
- No
Are you fluent in a language other than English?
- Yes
- No
If so, which?
PAST MILITARY RECORD
Have you ever served in the Armed Forces of the United States?
- Yes
- No
If yes, date entered
Date Format: MM slash DD slash YYYY
If yes, date discharged
Date Format: MM slash DD slash YYYY
Reserves or National Guard status?
- Yes
- N/A
IN CASE OF AN EMERGENCY, WHO SHOULD WE NOTIFY?
Name
First Last
Phone
Relationship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
JOB PREFERENCES
Select All That Apply
- 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?
- Yes
- No
Have you ever been excluded, suspended, or otherwise sanctioned by any federal or state health care program?
- Yes
- No
You may check my references
- Yes
- No
Additional Comments
I CERTIFY, by hitting ‘Submit’ 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.

Application for Employment

Application for Employment

PERSONAL RECORD

EDUCATION

COLLEGE

TRADE SCHOOL

PAST EMPLOYMENT REFERENCES

Reference 1

Reference 2

Reference 3

A LITTLE ABOUT YOURSELF…

PAST MILITARY RECORD

IN CASE OF AN EMERGENCY, WHO SHOULD WE NOTIFY?

JOB PREFERENCES