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Application for Employment

*Last Name:

*First Name:

Middle Initial:

*Email:

Web Page URL:

*Address:

*City:

*State:

*Zip:

*Home Phone:

Cell Phone:

*Social Security Number:

Position Desired:

Referred By:

Have you worked for
the following companies?

Central Coast Community Health Care, Inc.
Central Coast VNA & Hospice, Inc.
VNA Community Services, Inc.

What days and hours
are you available to work?:

*What status would you prefer?

Full Time Part Time Per diem

*Do you have the legal right to work
in the job for which you are applying?

Yes No MORE INFO

List languages you speak, read and/or
write other than English:
(optional)

#1		Speak	Read	Write
#2		Speak	Read	Write

*Are you 18 or older?

Yes No

*Have you, since the age of 18,
ever been convicted of a felony?

Yes No

Education

School Name	Complete Addresses of School	Academic Major	Dates Attended	Diploma?
			-
			-
			-
			-

Professional, Licenses, Registrations and/or Certifications

Type	State Issued	Date Issued	No.

Area of Specialization or Major Interest:

List any hobbies or interests, or membership in any club, organization, society or professional group that has a direct bearing on your qualification for the job which you are seeking. You may omit those which indicate your race, religion, creed, color, national origin, ancestry, sex, sexual orientation, physical or mental impairment, or medical condition.

Experience

List office machines you can use:

Typing Speed:

WPM

Check programs you can use:

Word Excel Outlook Power Point

Please list other equipment you can operate:

Give a complete record of all employment and reasons for periods unemployed during the past ten (10) years.

Last Employment Date	Employer's Name, Address	Telephone Number
-

Title:

Supervisor:

Summary of Duties:

Reason for Leaving:

May we contact for reference?

Yes No

Employment Date #2	Employer's Name, Address	Telephone Number
-

Title:

Supervisor:

Summary of Duties:

Reason for Leaving:

May we contact for reference?

Yes No

Employment Date #3	Employer's Name, Address	Telephone Number
-

Title:

Supervisor:

Summary of Duties:

Reason for Leaving:

May we contact for reference?

Yes No

Employment Date #4	Employer's Name, Address	Telephone Number
-

Title:

Supervisor:

Summary of Duties:

Reason for Leaving:

May we contact for reference?

Yes No

Employment Date #5	Employer's Name, Address	Telephone Number
-

Title:

Supervisor:

Summary of Duties:

Reason for Leaving:

May we contact for reference?

Yes No

Employment Date #6	Employer's Name, Address	Telephone Number
-

Title:

Supervisor:

Summary of Duties:

Reason for Leaving:

May we contact for reference?

Yes No

References

I authorize the company or individual listed below to furnish information regarding my employment history and performance to Central Coast Community Health Care, Inc and Affiliates (CCCHC). I hereby release all individuals and companies listed below from all liability for damage whatsoever that may be incurred as a result of furnishing such information.

	Reference #1	Reference #2	Reference #3
Contact Name:
Contact Title:
Company:
Address:
Phone:
Position Title:
Start Date:
End Date:
Reason for Leaving:

Resume

Upload your Resume (Word/RTF/PDF):

EEOC Questionnaire

The following statistical information is required for compliance with federal laws assuring equal employment opportunity. Your submission of the information is voluntary. The information you provide on this form will not be used to determine your eligibility or qualification for employment. It will remain in a confidential file separate from your employment application.

*Please select one EEO Code only:

	Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, orother Spanish culture or origin regardless of race.
	White (Not Hispanic or Latino) - A person having origins in any of the peoples of Europe, the Middle East, or North Africa.
	Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.
	Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands
	Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
	American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
	Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.

Affidavit

I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever. I agree that my employer shall not be liable in any respect if my employment is terminated because of the falsity of statements, answers or omissions made by me in this application. I authorize employers, companies, schools or persons to give any information regarding my employment, together with any information they may have regarding me whether or not it is in their records. I hereby release said employers, companies, schools or persons from all liability for any damage, both legal and otherwise, for issuing this information. I understand that the agency is committed to providing a safe, efficient and productive workplace. All offers of employment are conditioned upon successful completion of the pre-employment health screening. In addition, if accepted for employment, I hereby agree to abide by the rules and policies of my employer. I affirm that everything is true and correct, and I acknowledge that I can be terminated at anytime if any information I supply is false. I affirm that I have a genuine intent to seek employment and no other purpose in applying for a job with the agency.

Further, I understand that any employment is not for a stated period of time and may be terminated with or without cause, at any time, at the option of either myself or my employer with the decision of the president being final.

I Agree (by checking the box, you are agreeing to the above terms as if you signed your name)

We are an equal opportunity employer. Federal and State laws, and our personnel policies prohibit discrimination in employment because of race, color, creed, age, sex, sexual orientation, marital status, national origin, physical or mental impairment, or medical condition.

Home > Career Opportunities > Employment Application

Career Opportunities

Support VNA

Application for Employment

Education

Professional, Licenses, Registrations and/or Certifications

Experience

Give a complete record of all employment and reasons for periods unemployed during the past ten (10) years.

References

Resume

EEOC Questionnaire

Affidavit