<p> Application Instructions: 1. Fill out the application. 2. Highlight the completed application; copy and paste into an email. 3. Send to [email protected] </p><p>APPLICATION FOR EMPLOYMENT</p><p>DATE PERSONAL INFORMATION Last Name First Name Initial SSN</p><p>Address City State Zip</p><p>Home Phone Cell Phone Work Phone</p><p>E-mail address How did you hear about Visiting Angels?</p><p>Emergency Contact Relationship Phone home cell work Phone home cell work</p><p>EDUCATION HISTORY NAME & LOCATION YEARS DID YOU SUBJECTS STUDIED ATTENDED GRADUATE? HIGH SCHOOL</p><p>COLLEGE</p><p>OTHER</p><p>SPECIAL TRAINING / CERTIFICATION</p><p>CNA CHHA OTHER______List any other special training or skills</p><p>AVAILABILITY Please indicate the days and hours you are available to work DAYS Mon Tues Wed Thurs Fri Sat Sun </p><p>Hours EVENINGS Mon Tues Wed Thurs Fri Sat Sun </p><p>Hours OVERNIGHTS Mon Tues Wed Thurs Fri Sat Sun </p><p>Hours </p><p>Tell us why you would like to work for Visiting Angels:</p><p>FORMER EMPLOYERS (List most recent employer first) DATE NAME & ADDRESS OF EMPLOYER YOUR SALARY REASON FOR MONTH & YEAR POSITION LEAVING From Business Name Address To Phone From Business Name Address To Phone From Business Name Address To Phone From Business Name Address To Phone</p><p>PROFESSIONAL REFERENCES (List the names of at least three persons who know you professionally) REFERENCE NAME BUSINESS NAME ADDRESS PHONE YEARS RELATIONSHIP KNOWN (supervisor, co-worker, etc.)</p><p>AUTHORIZATION “ I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I authorize VA to conduct an identity, criminal and driving background checks in the Commonwealth of Massachusetts and in any countries, states and counties in which I may have resided during the past 20 years. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”</p><p>DATE SIGNATURE </p><p>FOR OFFICE USE ONLY Hired Date Termination Date </p>