Applicants are considered for positions without regard to race, color, religion, sex, creed, sexual orientation, age, national origin, marital or veteran status, or the presence of a non job-impacting handicap.
			Position Applied For   Admission Nurse Baylor RN Community/Marketing Liaison Home Care Aide Intake Clinician Personal Care Attendant Registered Nurse Registered Occupational Therapist Registered Physical Therapist Applicant Contact Information Full Name Street Address City/Town, State, Zip Email Telephone 1 Telephone 2 Emergency Contact Information Name Address Telephone Relationship Availability Available Date Full/Part-Time Full-Time Part-Time Per-Diem Per-Visit Any # Hours Requested How Did You Learn About This Opening? Licensing and Certification Home Health Aides Are You a Certified Home Health Aide?   Yes   No (nurses aide certification is not equivalent) Where Were You Trained? Certification Date Nurses/Therapists License # Expiration Date Driver's License Do You Have a Driver's License?   Yes   No Patient care positions require traveling to meet intermittent patient scheduling needs. A reliable means of transportation is therefore necessary for successful, continued employment in these positions. While we do not require owning an automobile as a condition of employment, patient care employees must be able to consistently keep to assigned service delivery schedules. Eligibility for Employment Are you legally eligible for employment in the US?   Yes   No The federal government requires that we inspect proof of legal eligibility for employment. Any offer of employment is subject to this verification. Foreign Languages Do You Speak Any Foreign Languages? Long Range Goals What Are Your Long Range Professional Goals? Resume Upload Resume (optional) Education School Graduation Major/Degree # Years School Graduation Major/Degree # Years School Graduation Major/Degree # Years Have You Completed Any Continuing Education Course or Special Training? Criminal Record Have You Ever Been Convicted of a Felony?        Yes   No Have you been convicted of a misdemeanor in the last five (5) years, which was not a first offence for: drunkenness, simple assault, speeding, minor traffic violation, an affray or disturbing the peace?        Yes   No If You Answered Yes to Either Question, Please Provide Details A conviction record will not necessarily be a bar to employment. Factors such as age at the time of offense, seriousness and nature of the violation, and rehabilitation will be taken into account. Failure to truthfully answer the above questions is grounds for immediate dismissal. Employment Experience - Work History Verified Volunteered Work May Be Included Employer Name Supervisor Telephone # Address City/Town, State, Zip Dates to Reason Left Ending Pay Work Performed Employer Name Supervisor Telephone # Address City/Town, State, Zip Dates to Reason Left Ending Pay Work Performed Employer Name Supervisor Telephone # Address City/Town, State, Zip Dates to Reason Left Ending Pay Work Performed Please Mention Here Any Supervisor You Would Rather Not Have Contacted Additional Information You Feel May Be Helpful to Us in Considering Your Application Professional References Name Relationship Telephone # Address Name Relationship Telephone # Address Name Relationship Telephone # Address By submitting this application, you are agreeing to the following: The answers given by me to all of the above questions are true and correct to the best of my knowledge. I understand that false or misleading information given in my application or interview(s) is grounds for denial of employment or termination upon post-employment discovery of falsification or omission. I give the employer the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information. It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. I understand that this application does not constitute an agreement, offer, or contract for employment. Any offer of employment is conditioned on the candidate's assertion that they meet the qualifications and physical requirements of the position as outlined in the job description. In addition, a patient care position is conditional and based on a physical examination by a physician indicating good health, negative TB test, and the ability to meet the physical requirements of the position. I understand it is GMVNA's policy not to refuse to hire a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA.