Vita Blue Home Care Employment Application
Language
  • English (US)
  • Español

  • Employment Application

  • Submitted Date
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  • Date of Birth*
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  • Have you resided at this address more than 2 years?*
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  • Best Time to Call*
  • Have you previously submitted an application with Vita Blue Home Care?*
  • How did you hear about Vita Blue Home Care?*

  • Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?*

  • Identification Information

  • Have you resided in the state of Pennsylvania for at least 2 years?*
  • ID/Driver's License Issue Date*
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  • ID/Driver's License Expiration Date*
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  • Availability Preferences

    Due to the nature of home care business, no guarantee can be made as to the schedule or the number of hours assigned. * Please complete all areas of availability.
  • What date are you available to begin work?*
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  • When are you available ?*
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  • Geographic Work Preferences*

  • Do you have a valid Driver's License?*
  • Do you own a vehicle?*
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  • Are you willing to provide service to a client with a pet?*
  • If yes, please specify which animals you are comfortable with.
  • Are you willing to provide service to a client who smokes?*

  • Job Related Skills

    Briefly describe any experience you may have.
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  • Pre-Employment Testing

    Briefly describe any experience you may have.
  • Do you have valid Tuberculosis Testing?*
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  • Are you being hired with a patient/client?*
  • If yes, are there children living in the home where the patients lives?

  • Education History

    For employment our minimum education requirement is either a GED or High School diploma.
  • Please select highest education completed:*
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  • Work Experience History

    Your application will not be considered unless all questions in this section are answered. We will make every effort to contact previous employers, providing correct telephone numbers for past employers are essential for verification.
  • Start Date*
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  • Currently Employed?*
  • Last Date Worked*
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  • Format: (000) 000-0000.
  • Can we contact?*

  • Past Work Experience

  • Start Date
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  • Last Day Worked
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  • Desired Salary

  • Background Questionnaire 

    As a condition of employment, all employees must be “Bondable” & “Insurable”.
  • Are you at least 18 years of age?*
  • Have you had any moving traffic violations for the past seven years?*
  • Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years?*
  • Have you been convicted of any offenses that may disqualify you of providing personal care services.*

  • References

    Please complete all references. Your application will not be considered unless TWO references are provided. Since we will contact these references, please notify them in advance. Family members cannot serve as references.
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  • Applicant Certification

  • I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief.  I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations.  I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between the Vita Blue Home Care (Company) and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.
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