APPLICATION FOR EMPLOYMENT - Victory Home Healthcare, Inc.

Aug 30, 2026

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Employment application form for applicants to Victory Home Healthcare, Inc., collecting personal information, desired position, work availability, and salary expectations. Includes questions about legal work eligibility, current employment status, ability to work overtime and travel, and driver’s license details. Collects education history, three personal references, prior employment experiences, military service, and professional certificates/licenses. Ends with applicant authorization and a disclaimer requiring truthful information and consent for reference and background investigation.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages4

Reading Time10 min

AccessFree to download

Applicant Information

Education

Personal References

Employment

Military Service

Certificate / License

Disclaimer and Signature

Applicant Authorization

|
APPLICATION FOR EMPLOYMENT | | --- | | We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status. APPLICANT INFORMATION | | Last Name First Name: M.I. Date: Street Address Apartment/Unit \#: | |
City State: ZIP: Phone E-mail Address Date Available to start: Social Security No.: Desired Salary Position Applying for (check one): HHA/CNA RN LPN PT OT ST MSW Other How did you hear about us? Advertisement Friend Relative Walk-in Employment Agency Other Are you available to work: Full-Time Part-Time Temporary Per-Diem On Call Days available Mon Tues Wed Thurs Fri Sat Sun Times available AM: From : To: PM: From: To: Will you work overtime if asked? YES NO Can you travel if job requires it? YES NO Driver’s license (if application to position) YES NO
State: Driver’s License \# Exp. Date:
_________
Are you prevented from lawfully
If you are under 18 years of age can you provide | | becoming employed in the United States YES NO
because of Visa or Immigration Status?
,
required proof of your eligibility to work?
YES
NO
Are you currently employed? YES NO May we contact your employer? YES NO Are you currently on a “lay-off” status and subject to recall? YES NO Have you ever been employed with us before? YES NO If yes, when? Have you ever filed an application with us before? YES NO If yes, when? Other special training , skills or qualification: Do you speak, read or write any foreign languages? YES NO If Yes, list language(s) | |
EDUCATION | | Graduate School Address From: To: Did you graduate? YES NO Degree | | College/University Address From: To: Did you graduate? YES NO Degree Business/Trade/ Technical Address From: To: Did you graduate? YES NO Degree High School Address From: To: Did you graduate? YES NO Degree Elementary Address From: To: Did you graduate? YES NO Degree | | --- | |
PERSONAL REFERENCES | |
Please list three references (who are not related to you). | |
(1)Full Name Relationship Company/Business Phone ( ) Address (2)Full Name Relationship Company/Business Phone ( ) Address (3)Full Name Relationship Company/Business Phone ( ) Address EMPLOYMENT: Start with your present or last job. Include any job-related military service assignments and volunteer activities. | | Employer Phone ( ) Address Supervisor Job Title Work Performed From: To: Reason for Leaving May we contact your previous employer for a reference? YES NO Employer Phone ( ) Address Supervisor Job Title Work Performed | | From: To: Reason for Leaving May we contact your previous employer for a reference? YES NO Employer Phone ( ) Address Supervisor Job Title Work Performed From: To: Reason for Leaving May we contact your previous employer for a reference? YES NO | | | --- | --- | |
MILITARY SERVICE | | | Branch From T
o | | | Rank at Discharge | Type of | |
CERTIFICATE / LICENSE Professional: RN LPN PT OT ST MSW Other
Reg. /License: YES NO State Reg./License \# Exp. Date:
CNA Certificate: YES NO Date :
Home Health Aide Certificate: YES NO Date :
Homemaker or PCA Training Certificate: YES NO Date : DISCLAIMER AND SIGNATURE I certify that my answers are true, correct and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. Signature Date
Discharge | | | Victory Home Healthcare, Inc.
P.O Box 545
Holyoke, MA 01041-0545 Phone: (413) 315-3593
Fax: (413) 315-3088
[www.victoryhhc.com](www.victoryhhc.com) | | | Applicant Authorization
PLEASE READ AND UNDERSTAND THIS STATEMENT BEFORE SIGNING YOUR APPLICATION
❖ Thank you for your interest in employment with Victory Home Healthcare, Inc. Victory

FAQs

What personal details and work availability does the application request?

The form asks for applicant name, address, contact information, date available to start, desired salary, and the position applied for. It also requests availability for full-time, part-time, temporary, per-diem, on-call, including specific days and time ranges.

Does the application include eligibility and background consent questions?

Yes. It asks whether the applicant is prevented from working lawfully in the United States due to visa or immigration status, and whether the applicant authorizes investigation of statements and references. It also includes a release of liability for information use and consent for physical examinations if required.

What supporting records does the form collect for qualification verification?

The application requests education details, three personal references, employment history with supervisor and reason for leaving, and military service information. It also collects professional certificates/licenses such as RN/LPN and home health aide-related certificates with states and expiration dates.

Aug 30, 2026

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