Employment Appliciation

Thank you for your interest in Vision Healthcare Services! To get started, simply fill out the form below and one of our experts will reach out to you regarding employment opportunities.

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Basic Information

Position (required)

First Name (required)

Street

State

Phone (required)

Fax Number


Are you a citizen of the United States?
Do you have a valid drivers license?

Have you recently had your finger prints taken by a Homecare Agency for a Criminal History Record Check? (required)

Have you ever been convicted of a felony? (required)

Have your credentials ever been under investigation? (required)

If ‘Yes’ to either of the above, please supply details describing the incident.

Professional Certification/Licensure

Nurse’s License



StateExpiration DateDay

Year

CNA License



StateExpiration DateDay

Year

Certifications

Professional Experience

Please check areas of clinical expertise that you are applying for:
 Acute Care Long Term Care Pediatrics Home Health Hospital M.D. Office Rehabilitation Skilled nursing Hospice

List any pertinent skills other than work experience that we should consider.


Check Hours that best apply to you: Days Nights Weekends Live In

Schedule
 Full Time Part Time

Date available to start:

Employment

Prior Employment

Employer Name

Street

State

Date Started

Supervisor

Description of Duties/Responsibilities

Reasons for leaving this job

May we contact your previous employer? Yes No

Employment 2

Employer Name

Street

State

Date Started

Supervisor

Description of Duties/Responsibilities

Reasons for leaving this job

May we contact your previous employer? Yes No

How did you hear about Vision Homcare Services?

Attach Your Resume

I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the company’s rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the company. I understand that no company representative, other than its President, and then only when in writing and signed by the President, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the forgoing.

Today’s Date



MonthDay

Year

Signature(required)

Please type your name here as your signature

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We understand there is no place like home. We are committed to supporting the decision for seniors to remain in their home where they can maintain a healthy sense of independence and personal dignity