NORVA Home Health Care Application Form

APPLICATION FORM

Read the questions carefully and fill in all information asked of.
PERSONAL INFORMATION
Name:

First NameMiddle NameLast Name
Address:

Street Address

CityState

Zip Code
Social Security Number:
Format: AAA-GG-SSSS
Cell Phone Number:
Home Phone Number:
Your email address:
example@example.com
Age: (if you are under 18 years of age)
Type in your age.
Please indicate the dates and times your are available to work:

AnytimeWeekends only

	From	To
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Position applied for:

PCAOther
Salary range desired:
ex. $15/hr
How many hours can you work weekly?
ex. 15 hours
Are you available to work nights?

YesSomeNo
Are you available to work weekends?

YesSomeNo
Would you consider live-in?

YesNo
Employment desired:

Part-time onlyFull-time or part-timeFull-time only
Are you legally authorized to work in the United States?

YesNo
When are you available to work?

AnytimeAs soon as possibleOther
Where did you hear about us?

EDUCATION INFORMATION

Fill in the table below.

	Name of School	Location (City, State)	Years Completed	Major and Degree
High School
College
Business and Trade School
Professional School

WORK EXPERIENCE

Please list at least two of your work experiences for the last five years, beginning with your most recent job held. If you were self-employed, give company name.

Most Recent Reference (Click to expand)
Employer's Name:
Employer's Address:

Street Address

Street Address Line 2

CityState

Zip Code
Employer's Phone Number:

Area CodePhone Number
Name of last supervisor:

First NameLast Name
Start Date

MonthDayYear
End Date

MonthDayYear
Start Pay/Salary
Final Pay/Salary
Reason for leaving (be specific)
List the jobs you held, duties preformed, skills used or learned, advancements or promotions while you worked here:
May we contact your present employer?

YesNo
If you answered "NO", then please explain why and provide us with another work reference below.
Explain why we cannot contact your employer in the box above. Then provide another work reference below.

Work Reference 2 (Click to expand)
Employer's Name:
Employer's Address:

Street Address

Street Address Line 2

CityState

Zip Code
Employer's Phone Number:

Area CodePhone Number
Name of last supervisor:

First NameLast Name
Start Date

MonthDayYear
End Date

MonthDayYear
Start Pay/Salary
Final Pay/Salary
Reason for leaving (be specific)
List the jobs you held, duties preformed, skills used or learned, advancements or promotions while you worked here:
May we contact this employer?

YesNo
If you answered "NO", then please explain why and provide us with another work reference below.
Explain why we cannot contact your employer in the box above. Then provide another work reference below.

Work Reference 3 (Click to expand)
Employer's Name:
Employer's Address:

Street Address

Street Address Line 2

CityState

Zip Code
Employer's Phone Number:

Area CodePhone Number
Name of last supervisor:

First NameLast Name
Start Date

MonthDayYear
End Date

MonthDayYear
Start Pay/Salary
Final Pay/Salary
Reason for leaving (be specific)
List the jobs you held, duties preformed, skills used or learned, advancements or promotions while you worked here:
May we contact this employer?

YesNo
If you answered "NO", then please explain why:
Explain why we cannot contact your employer in the box above.

CONTRACTOR DATA FORM WAIVER

Please read the following wavier carefully.
In exchange for the consideration of my job application or service agreement with NORVA HHC (hereinafter called “the Company”), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Norva HHC, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President/General Manager of the Company. Both the undersigned and Norva HHC may end the employment or working relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits. Independent Contractor has no employment benefits.

I understand that for regular employment purposes, (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I also understand that, in connection with the routine processing of employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I hereby release any and all prior employers or current employers from liability or claims arising out of the provision of information about my employment with such employer. I hereby waive any cause of action I might otherwise have against such employer arising out of the provision of information concerning my employment.

When classified as an employee, I further understand that my employment with the Company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE. I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal or revocation of any agreement I have made at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.
Do you agree with the terms?

YesNo

SWORN STATEMENT OR AFFIRMATION

Please read the following.
To the Applicant:

Section 32.1-162.9 of the Code of Virginia requires that any person desiring to work at a licensed home care organization shall provide the hiring facility with a sworn statement or affirmation disclosing any criminal convictions or any pending criminal charges, whether within or outside the Commonwealth of Virginia.

The law prohibits licensed home care organizations from hiring any individuals convicted of a barrier crime (specified below). However, applicants convicted of one misdemeanor barrier crime not involving abuse or neglect may be hired if five years has elapsed since the conviction. Any person making a false statement on this form regarding any criminal offense shall be guilty of a Class 1 misdemeanor.

Further dissemination of the information provided on this form is prohibited other than to the Commissioner’s representative or a federal or state authority or court as may be required to comply with an express requirement of law for such further dissemination.
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law?

YesNo
If you answered "YES", list all and explain.
Are you the subject of any pending criminal charges?

YesNo
If you answered "YES", please explain.
Have you ever been sanctioned or had your licenses suspended or revoked?

YesNo
I hereby affirm that the information provided on this form is true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part to any employment offered by this facility. I understand that all information on this form is subject to verification.

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Applicant's Signature:

Clear
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APPLICATION FORM

EDUCATION INFORMATION

PROFESSIONAL LICENSES AND/OR CERTIFICATIONS

DRIVING INFORMATION

PERSONAL REFERENCE INFORMATION

WORK EXPERIENCE

CONTRACTOR DATA FORM WAIVER

SWORN STATEMENT OR AFFIRMATION

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