Valley Memorial Homes
Application for Employment
Hours/Days/Shifts You CANNOT Work:
Certified Nurses Assistant
Have you ever been arrested, charged or convicted of abusing, neglecting or mistreating individuals in a healthcare related setting?
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.
If you have completed education beyond high school graduation or equivalency, please state the degree held, if any:
“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
If No Previous Work Experience, List One Personal Reference (Nursing Applicants: Please List One Nursing Instructor).
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and regulations of Valley Memorial Homes and acknowledge that these rules and regulations may be changed, interpreted, withdrawn, or added to, by Valley Memorial Homes at any time and without prior notice to me.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.
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.
Valley Memorial Homes
Consent to Perform Criminal History/Background Check
In Compliance with the FCRA (Fair Credit Reporting Act)
Maiden or other name(s) used in any and all other records of birth or records of residence.
* - 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).
Details of Conviction:
2. Have you ever received deferred adjudication or similar disposition for any federal, state or municipal offence?
Details of Offence:
3. Have you ever received probation or community supervision for any federal, state or municipal offence?
Details of Supervision:
4. Have you ever been convicted of any criminal offence in a country outside the jurisdiction of the United States?
Details of Conviction:
5. As of the date of the consent form, do you have any pending charges against you?
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.
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.
day of ,
I CERTIFY I AM THE PERSON WHOSE NAME IS SIGNED BELOW AND THAT MY TYPED NAME REPRESENTS A LEGALLY BINDING SIGNATURE.