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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.","| \u003Cbr>APPLICATION FOR EMPLOYMENT |\n| --- |\n| 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 |\n| Last Name First Name: M.I. Date: Street Address Apartment/Unit \\#: |\n| \u003Cbr>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\u003Cbr>State: Driver’s License \\# Exp. Date:\u003Cbr>_________\u003Cbr>Are you prevented from lawfully\u003Cbr>If you are under 18 years of age can you provide |\n| becoming employed in the United States YES  NO \u003Cbr>because of Visa or Immigration Status?\u003Cbr>,\u003Cbr>required proof of your eligibility to work?\u003Cbr>YES\u003Cbr> NO \u003Cbr>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) |\n| \u003Cbr>EDUCATION |\n| Graduate School Address From: To: Did you graduate? YES  NO  Degree |\n\n\n| 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 |\n| --- |\n| \u003Cbr>PERSONAL REFERENCES |\n| \u003Cbr> Please list three references (who are not related to you).  |\n| \u003Cbr>(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. |\n| 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 |\n\n\n| 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  |  |\n| --- | --- |\n| \u003Cbr>MILITARY SERVICE |  |\n| Branch From T\u003Cbr>o |  |\n| Rank at Discharge | Type of |\n| \u003Cbr>CERTIFICATE / LICENSE Professional: RN LPN  PT  OT  ST  MSW  Other  \u003Cbr>Reg. /License: YES  NO  State  Reg./License \\#   Exp. Date:  \u003Cbr>CNA Certificate: YES  NO  Date :  \u003Cbr>Home Health Aide Certificate: YES  NO  Date :  \u003Cbr>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.\u003Cbr>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\u003Cbr>Discharge |  |\n| Victory Home Healthcare, Inc.\u003Cbr>P.O Box 545\u003Cbr>Holyoke, MA 01041-0545 Phone: (413) 315-3593\u003Cbr>Fax: (413) 315-3088\u003Cbr>[www.victoryhhc.com](www.victoryhhc.com) |  |\n\n\n| Applicant Authorization\u003Cbr>PLEASE READ AND UNDERSTAND THIS STATEMENT BEFORE SIGNING YOUR APPLICATION\u003Cbr>❖ Thank you for your interest in employment with Victory Home Healthcare, Inc. Victory","cbCaitH8UIAc8MoF","https://ap.wps.com/l/cbCaitH8UIAc8MoF","pdf",252276,1,4,"English","en",105,"# Applicant Information\n## Education\n## Personal References\n## Employment\n## Military Service\n## Certificate / License\n## Disclaimer and Signature\n## Applicant Authorization","[{\"question\":\"What personal details and work availability does the application request?\",\"answer\":\"The form asks for applicant name, address, contact information, date available to start, desired salary, and the position applied for. 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