Ann Virginia Home Care Agency

(919) 294-8225

APPLY HERE !

Please send us a message at annvirginianc@gmail.com
Last Name First Name Middle SSN DOB E-mail Address City/State/Zip Phone
Position Applying For
PCA
NAI
NAII
RN
Administration
Date Available
Previous Facility Types Worked: (circle all that apply)
Hospital
Hospice
Nursing Home
Rehab
Private Duty
Assisted Living/Residential Treatment
Language Skills: Other than English, please select any other languages you speak.
Spanish
French
German
Other
Other language spoken
Select the type of assignment you are available for:
Part-Time
Full-Time
Contract
Travel
Circle the days of the week you are available to work:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Holidays available to work 1. License Type License/Certification # State & Expiration Date 2. License Type License/Certification # State & Expiration Date 3. License Type License/Certification # State & Expiration Date
Has your professional license ever been suspended, revoked or under investigation?
Yes
No
If yes, please explain Certifications: List all that applicable certifications and expiration dates. 1. EMPLOYMENT - Facility/Employer Name Address City/State/Zip Country Number of Beds in Unit: (if applicable)
In Hospital
Yes
No
Job Duties Pay Rate/Salary Pay Rate/Salary Reason for leaving
Are your employment records listed under another name?
Yes
No
If yes, what name? Dates Employed Title Unit (if applicable) Name of Immediate Supervisor Phone
May we Contact
Yes
No
If NO, why?
Supervisory Experience
Yes
No
2. EMPLOYMENT - Facility/Employer Name Address City/State/Zip Country Number of Beds in Unit: (if applicable)
In Hospital
Yes
No
Job Duties Pay Rate/Salary Pay Rate/Salary Reason for leaving
Are your employment records listed under another name?
Yes
No
If yes, what name? Dates Employed Title Unit (if applicable) Name of Immediate Supervisor Phone
May we Contact
Yes
No
If NO, why?
Supervisory Experience
Yes
No
Please list any other work-related information that you think would be helpful to us in considering you for employment, such as specialized training, certifications, additional work experience, etc.
Are you legally authorized to work in the USA?
Yes
No
Have you ever been convicted of a felony?
Yes
No
Can you pass a pre-employment drug test?
Yes
No
How were you referred to Ann Virginia Home Care Agency? I understand that I must report all accidents to my immediate supervisor and to Ann Virginia Home Care Agency----No MATTER HOW SLIGHT. I also understand that I must wear all required personal protection equipment (PPE). (The penalty for not wearing PPE is disciplinary action, up to and including termination) ACKNOWLEDGMENT (please read carefully and sign) I certify that the information contained in this application is correct to the best of my knowledge. I understand that to falsify information is grounds for refusing to hire me, or for discharge should I be hired. I authorize any person, organization, or company listed on this application to furnish you all information concerning my previous employment, education, and qualifications for employment. I also authorize you to request and receive such information. In consideration for my employment, I agree to abide by the rules and regulations of the company, which rules may be changed, withdrawn, added, or interpreted at any time, at the company’s sole option and without prior notice to me. I acknowledge that my employment may be terminated, or any offer or acceptance of employment withdrawn, at any time, by either myself or Ann Virginia Home Care Agency, for any reason not expressly prohibited by law. I understand that Ann Virginia Home Care Agency is not involved in the day-to-day supervision or decision concerning patient care or dentistry. This remains with the Professional as part of the Professionals practice. The professional fully indemnifies Ann Virginia Home Care Agency against all liability associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law. I HAVE READ THE ABOVE STATEMENTS AND FULLY UNDERSTAND IT. Today's Date ANN VIRGINIA HOME CARE AGENCY AUTHORIZATION TO RELEASE AND CHECK INFORMATION Applicant Name City/State/Zip DOB SSN I hereby authorize Ann Virginia Home Care Agency to perform criminal background/DMV checks to disclose in God faith any information they may need regarding information to the employment process. I understand if I do not agree to authorize the release of the criminal background/DMV check, I will have to forfeit my employment opportunity. I verify the enclose information is valid. Today's Date Send application