Employment Application


Valley Memorial Homes
Application for Employment

Date of Application
Date of Availability
Location
Last Name
First Name
Middle Initial
Address
City
State
Zip
Phone #
Cell Phone
Email
Social Security Number

Availability

Are you eligible to work in the United States?
Yes    No
Are you over 16 years of age?
Yes    No
Position Applied For
Would you be willing to consider other VMH positions?
Yes    No
Would you accept:

Hours/Week

How Long
Many of our positions are weekends/shifts. Would you accept:
Shifts
Weekend Work
Hours/Days/Shifts You CANNOT Work:
Were you formerly employed at any VMH facility? (i.e. Valley Eldercare Center, 4000 Valley Square, Tufte Manor, Almonte Living Center)
Yes    No
If yes, what facility and year?

Certified Nurses Assistant

Have you ever been employed as a CNA?
Yes    No
If yes, list states you have previously worked in:
Current CNA Certificate #
State Where Issued
Exp. Date

Criminal Record

Have you ever been convicted of a felony?
Yes    No
If yes, a record will not necessarily bar you from being employed at Valley Memorial Homes. Age and time of the offense, seriousness and the nature of the violation, and rehabilitation will be taken into consideration.
Have you ever been arrested, charged or convicted of abusing, neglecting or mistreating individuals in a healthcare related setting?
Yes    No
If yes, attach an individual page and explain in detail, include dates, places, charges and results. Under Federal Regulations, conviction of resident abuse, neglect or mistreatment or misappropriation of resident property will disqualify you from consideration of employment.
Education Data
Do you have a high school degree or equivalency?
Yes    No
Name of last school attended
If you have completed education beyond high school graduation or equivalency, please state the degree held, if any:
Degree (type)
Diploma
Major Area of Study
Other education relevant to position
Dates
ND License, Certificate, or Permit Numbers
Expiration Date

“Valley Memorial Homes provides compassionate care and service, from a Christian perspective,
to enhance the quality of life for those we serve.”
An Equal Opportunity Employer
Valley Memorial Homes is a smoke free workplace.

Present or Most Recent Employment Information
Firm
Phone
Address
City
State
Zip
Your Name While Employed There For Reference Request
Name Of Immediate Supervisor
Starting Title
Starting Salary
Date Began
Present Title
Present Salary
Date Left
Duties
Why Do You Wish To Make A Change?
May We Contact?
Yes    No
Previous Experience
Firm
Phone
Address
City
State
Zip
Your Name While Employed There For Reference Request
Name Of Immediate Supervisor
Starting Title
Starting Salary
Date Began
Present Title
Present Salary
Date Left
Duties
Why Do You Wish To Make A Change?
May We Contact?
Yes    No
Previous Experience
Firm
Phone
Address
City
State
Zip
Your Name While Employed There For Reference Request
Name Of Immediate Supervisor
Starting Title
Starting Salary
Date Began
Present Title
Present Salary
Date Left
Duties
Why Do You Wish To Make A Change?
May We Contact?
Yes    No
If No Previous Work Experience, List One Personal Reference (Nursing Applicants: Please List One Nursing Instructor).
Name
Phone
Address
City
State
Zip

Applicant's Certification

I certify that all matters contained in this application are true, authorize their investigation and agree that any mis leading or false statements would render this application void and could be sufficient cause for immediate dismissal in the event of employment.

I understand that my employment is dependent upon receipt of satisfactory reference, attendance at orientation and satisfactory completion of the appraisal period.

I agree, if employed, to provide licensure (when applicable) and abide by the Corporate Rules and Regulations.

I agree to conform to the rules and regulations of Valley Memorial Homes and acknowledge that these rules and regulations may be changed, interpreted, withdrawn, or added to, by Valley Memorial Homes at any time and without prior notice to me. I understand that nothing contained in this employment contract between Valley Memorial Homes and myself for either employment or for the providing of any benefits. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Corporation unless expressly made in writing. If an employment relationship is established, I understand that I have the right to terminate my employment at any time, and Valley Memorial Homes retains a similar right regarding the discontinuation of my employment.

Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital, or the presence of a physical or mental handicap or disability, or any other characteristic protected by law. It is our intention that all applicants be given equal opportunity and that selection decisions are based on job-related factors.

Signature:
Date:
I hereby authorize my former employers, school officials and other persons with whom I have been professionally associated to give Valley Memorial Homes any information regarding my employment record, together with any information they may have regarding whether or not such information is on their records. I hereby release said companies and individuals for any liability for any damage whatsoever resulting from the giving of such information.
Applicant's Name
Date

 


 

Valley Memorial Homes

Consent to Perform Criminal History/Background Check
In Compliance with the FCRA (Fair Credit Reporting Act)

Last Name
First Name
Middle Initial
Maiden or other name(s) used in any and all other records of birth or records of residence.
Address
Apartment #
City
County
State
Zip
** Date of Birth
Social Security Number
** Gender
** Race
* - as shown on the original application
** - to be used for criminal history checks only and not a part of the personnel file.
I, , am an applicant for employment/volunteerism with Valley Memorial Homes and have been advised that as a part of the application process, VMH conducts a criminal background check. I do hereby consent to VMH use of any information provided during the application process in performing the criminal history check. VMH has informed me that I have the right to review and challenge any negative information that would adversely impact a decision to offer employment/volunteerism. In addition, I have been informed that I will have a reasonable opportunity to clear up any mistaken information reported within a reasonable time frame established within the sole discretion of VMH. Under the Fair Credit Reporting Act, I have been advised that upon request I will be provided the name, address and telephone number of the reporting agency as well as the nature, substance and source of all information.
The following are my responses to questions about my criminal history (if any).
1. Have you ever been convicted or plead guilty before a court for any federal, state or municipal criminal offence? (exclude minor traffic misdemeanors).
Yes    No
If yes, please provide details below.
State
County
Date of Offence
Details of Conviction:
2. Have you ever received deferred adjudication or similar disposition for any federal, state or municipal offence?
Yes    No
If yes, please provide details below.
State
County
Date of Offence
Details of Offence:
3. Have you ever received probation or community supervision for any federal, state or municipal offence?
Yes    No
If yes, please provide details below.
State
County
Date of Offence
Details of Supervision:
4. Have you ever been convicted of any criminal offence in a country outside the jurisdiction of the United States?
Yes    No
If yes, please provide details below.
City
County
Date of Offence
Details of Conviction:
5. As of the date of the consent form, do you have any pending charges against you?
Yes    No
If yes, please provide details below.
State
County
Date of Arrest
Details of Pending Charges:
THIS SECTION IS TO BE USED TO LIST ALL THE COUNTIES AND STATES OF RESIDENCE SINCE HIGH SCHOOL GRADUATION OR AGE 18.
City/Town
County
State
I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS CONSENT FORM IS TRUE, CORRECT, AND COMPLETE. IF ANY INFORMATION PROVES TO BE INCORRECT OR IMCOMPLETE I UNDERSTAND THAT GROUNDS FOR CANCELLING OF ANY AND ALL OFFERS OF EMPLOYEMENT/VOLUNTEERISM WILL EXIST AND MY BE USED AT THE DISCRETION OF VMH.
Signed this day of ,
I CERTIFY I AM THE PERSON WHOSE NAME IS SIGNED BELOW AND THAT MY TYPED NAME REPRESENTS A LEGALLY BINDING SIGNATURE.
Applicant's Name
PDF Version (Print Application)