Employment Application – A & A Home Health Care

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Employment ApplicationSystem Administrator2018-09-02T14:03:55-04:00

A & A Employment Application

Please complete the employment application

Step 1 of 6 - Application Information

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Select Position*
- LPN - Hampton Roads Metro
- RN - Hampton Roads Metro
- CNA - Hampton Roads Metro
- Care Manager Coordinator
- Care Manager - Suffolk, VA (including Waverly, Windsor, Franklin, Emporia)
- Care Manager - Southside (Norfolk, Portsmouth, Virginia Beach, Chesapeake)
- Care Manager - Peninsula (Newport News, Hampton, Williamsburg)
- Care Manager - Richmond and Surrounding Metro
- Sponsored Residential Home
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Date Available
MM slash DD slash YYYY
Current Salary
Position Desired
- Part-Time
- Full-Time
- Permanent
- Temporary
Desired Salary
Are you a citizen of the United States?*
- Yes
- No
If no, are you authorized to work in the United States?*
- Yes
- No
Have you ever worked for A & A before?*
- Yes
- No
If so, when?
- Yes
- No
Have you ever been convicted of a felony?
- Yes
- No
If yes, explain?
SSN*
Nursing License Number*
State Issued*
Driver's License Number*
State Issued*

Did you graduate high school?*
- Yes
- No
Name of High School
Graduation Date
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State ZIP Code
Did you receive your GED?
- Yes
- No
Date GED Received
MM slash DD slash YYYY
State Received*
Other School or Certification
Address
Street Address Address Line 2 City State ZIP Code
Describe the school and/or certification
Do you have experience working with any of the following population (developmental delayed, elderly, intellectually disabled, mentally challenged)?
- Yes
- No
For SPONSORED RESIDENTIAL Candidates
If YES, how many TOTAL years experience?

Reference 1 - Name*
First Last
Company Name
Address
Street Address Address Line 2 City State ZIP Code
Phone*
Relationship*
Reference 2
Reference 2 - Name*
First Last
Company Name
Address
Street Address Address Line 2 City State ZIP Code
Phone*
Relationship*
Reference 3
Reference 3 - Name*
First Last
Company Name
Address
Street Address Address Line 2 City State ZIP Code
Phone*
Relationship*

Did you serve in the Armed Forces?*
- Yes
- No
Branch
Service Date: From
MM slash DD slash YYYY
Service Date: To
MM slash DD slash YYYY
Rank at Discharge
Type of Discharge
- Honorable
- General
- Other Than Honorable
If other than Honorable, explain

Acknowledgement*
- I certify that my answers are true and complete to the best of my knowledge.
I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning previous my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from liability for any damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice."

If this application leads to employment, I understand that false or misleading information in my application or interview will result in my release.

I further certify that there are no pending criminal convictions within or outside of the Commonwealth of Virginia.
Name
This field is for validation purposes and should be left unchanged.

4433 GODWIN BLVD, STE B - SUFFOLK, VA 23434 757.934.3935
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