Visiting Nurse Association | South Central Connecticut

	Home
	About us
	Services
	Choosing the Right Home Health Care
	Choosing the Right Home Health Care
	News, Events & Publications
	Areas We Serve
	Support Us
	Career & Volunteer Opportunities
	Nightingale
	Contact Us
	Resources

Online Application

Personal

First Name
Middle Initial
Last Name
Telephone Number
Present Address
City
State
Zip Code
Cellular Number
Permanent Address (if different)
City
State
Zip Code
E-mail Address
Work Telephone Number
Have you ever worked at the VNA/SCC?	YES NO
If Yes, Dates Employed
Position And Department
Do you have relatives or friends employed at the VNA/SCC?	YES NO
What relationship?
Department
If hired, Can you provide written evidence that you are legally authorized to work in the United States?	YES NO

Position

First Position applied for :
Salary Desired
Second Position applied for :
Salary Desired
Hours Available	Full Time Part Time Per Diem Temporary Summer
How did you hear about this Position?	Job Posting Website Job Fair Open House Walk-In Conference Advertisement Other (Please Specify Source)

Education

High School
Name and Address of School
Last Year Completed	1 2 3 4
Did You Graduate?	YES NO
Course/Diploma
College
Name and Address of School
Last Year Completed	1 2 3 4
Did You Graduate?	YES NO
Course/Diploma
Other (Business College/Trade School/Other Special Courses/Areas of Specialization of Major Interest)
Name and Address of School
Last Year Completed	1 2 3 4
Did You Graduate?	YES NO
Course/Degree

Skills

Are you Currently:	Registered Licensed Certified Eligible For: Registration Licensure Certification
Please list any special qualifications, skills, occupational licenses, certificates
Type
State Issued
Date of Issue
Expiration
Number

Please indicate your special skills by checking appropriate boxes:
Spreadsheets (i.e.,Excel)
Word Processing (i.e. MS Word)}
Data Bases(Access)
Medical Terminology
Switchboard: Type
Other Computer Applications:
Fluency in Foreign Language: (Specify)
Please list any other work related skills not mentioned:

Work Experience

List Most Recent Experience First
» 1)
Name of Company
Address
City
State
Time Employed	From To
Position
Salary
Reason for Leaving:
Describe your Duties and Responsibilities

» 2)
Name of Company
Address
City
State
Time Employed	From To
Position
Salary
Reason for Leaving:
Describe your Duties and Responsibilities

» 3)
Name of Company
Address
City
State
Time Employed	From To
Position
Salary
Reason for Leaving:
Describe your Duties and Responsibilities

References

May the VNA/SCC contact your present employer?	YES NO
» 1)
Name
Address
Telephone Number
Business Occupation
Relationship
» 2)
Name
Address
Telephone Number
Business Occupation
Relationship
» 3)
Name
Address
Telephone Number
Business Occupation
Relationship

Other

Have you ever been Convicted of a crime?	YES No
("Convicted" means pleading guilty to a crime, or being found guilty by a court after trial).You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to section 46b-146,54-76o or 54-142a of the Connecticut General Statutes. Criminal Records subject to erasure pursuant to these statutes are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty or a conviction for which the person received an absolute pardon. Any person whose criminal records have been erased pursuant to these statutes shall be deemed to have never been arrested within the meaning of the general statutes with respect to the proceedings so erased and may so swear under oath.
If you checked "YES", Please indicate as to each conviction:
The jurisdiction: i.e.,state, foreign country
The offense:
The date:
The penalty imposed:
I understand that any criminal convictions will not automatically disqualify me from employment . Factors such as age and time of offense, seriousness and nature of the violation and rehabilitation will be taken into account. I understand that employment will be subject to my submitting documentary proof of my identity and eligibility to legally work in the United States. I understand that if employed, I will be an “employee at will”, which means that both the VNA/SCC and I can terminate my employment at any time, for any reason consistent with the applicable state and federal law. I understand that the VNA/SCC may thoroughly investigate my work and personal history and verify all data given on this application, on related papers, and in interviews. I authorize all individuals, schools, and employers named therein, except my current employer, if so noted, to provide any information requested about me, and I release all parties involved from any and all liability arising out of the release of this information. I certify that I am under no contractual obligations that would preclude me from working for the VNA/SCC. I further certify by submission of this application that all statements herein are true and understand that any falsification, misleading information or material omissions may result in refusal of employment, or, if hired, may result in termination of employment.