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Page 1 of 4: Personal Information

* Required Fields

Date: 
*First Name: 
MI: 
*Address: 
 
*City: 
*State:  *Zip: 
*Position Applied For: 
*Last Name: 
*Day Phone: 
Evening Phone: 
Mobile Phone: 
Email: 
*If hired, can you present evidence of your legal right to live and work in the USA? (proof required upon employment)
Yes No
*If you are under 18 years of age, can you provide required proof of your ability to work?
Yes No
*Are you looking for: full time part time per diem employment
If per diem, please specify days & hours: 
*Willing to work evenings:  Yes No
*Willing to work weekends:  Yes No
*Willing to work holidays:  Yes No
*Willing to be "on call":  Yes No
*Willing to work overtime:  Yes No
*Willing to accept shift rotation:  Yes No
*Were you previously employed by us: Yes No
If yes, when: 
What capacity: 
*Is any information relative to change of name, use of an assumed name or nickname necessary to enable us to check your work and educational record?
Yes No
If yes, explain: 
How did you learn about the VNA?
VNA Employee     Newspaper     Radio     VNA Website     Other
Specify:
List any friends or relatives working for us or on the Board of Directors. Please specify relationship.
*If your application is considered favorably, on what date would you be available to work?
      

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