Application for Employment

1 Contact Info

2 Position

3 Education

4 Experience

Date of Application:*
Date Format: MM slash DD slash YYYY
Which branch are you applying for?*
Valley Regional Home Health and Hospice, Inc., a California corporation (“Valley Regional Home Health and Hospice”) is an equal employment opportunity employer. The Company’s policy is not to discriminate against any applicant or employee based on race, color, sex, religion, national origin, age (40 and over), disability, military status, genetic information, or any other basis protected by applicable federal, state, or local laws. Valley Regional Home Health and Hospice also prohibits harassment of applicants or employees based on any of these protected categories. It is also Valley Regional Home Health and Hospice’s policy to comply with all applicable federal, state, and local laws respecting consideration of unemployment status in making hiring decisions.
First Name:*
Middle Name:
Last Name:*
Current Address:*
Street Address City State ZIP Code
Home Phone:
Mobile Phone:
Alternate Phone:
Email Address:*
Have you ever been employed with Valley Regional Home Health and Hospice before?*
- Yes
- No
From:*
Date Format: MM slash DD slash YYYY
To:*
Date Format: MM slash DD slash YYYY
Reason for leaving?*
Have you ever applied for a position with Valley Regional Home Health and Hospice before?*
- Yes
- No
Date of application:*
Date Format: MM slash DD slash YYYY
For what position?*
Do you have any relatives who are employed with Valley Regional Home Health and Hospice?*
- Yes
- No
Name:*
Relationship:*

V. EMPLOYMENT EXPERIENCE
Starting with current employment, if any, please list employment history in reverse order:
Present or last employer:*
Address*
Street Address City State ZIP Code
Dates of employment from:*
Date Format: MM slash DD slash YYYY
To:*
Date Format: MM slash DD slash YYYY
Position(s) held:*
Describe your duties:*
Name and title of immediate supervisor:*
Reason for leaving:*
May we contact your current or last employer?*
- Yes
- No
Prior employer:
Address
Street Address City State ZIP Code
Dates of employment from:
Date Format: MM slash DD slash YYYY
To:
Date Format: MM slash DD slash YYYY
Position(s) held:
Describe your duties:
Name and title of immediate supervisor:
Reason for leaving:
Prior employer:
Address
Street Address City State ZIP Code
Dates of employment from:
Date Format: MM slash DD slash YYYY
To:
Date Format: MM slash DD slash YYYY
Position(s) held:
Describe your duties:
Name and title of immediate supervisor:
Reason for leaving:
REFERENCES: Please provide the names, addresses, and telephone numbers of two references who are not related to you:
Name:*
Telephone No.:*
Address*
Street Address City State ZIP Code
Name:*
Telephone No.:*
Address*
Street Address City State ZIP Code
VI. ACKNOWLEDGMENT AND SIGNATURE
I certify that all the information contained within this application (and any and all attachments) is true and correct to the best of my knowledge, and I understand that any false information or omissions may lead to the rejection of my application or, if I am employed, discipline up to and including termination at the time any such false information or omission is discovered.

I authorize investigation of all statements contained within this application; authorize Valley Regional Hospice to secure information about my background and experience with former employers, educational institutions, and any relevant agencies; and authorize those parties to provide information to Valley Regional Hospice concerning my background and experience.

I understand that, if I am employed, my employment with Valley Regional Hospice can be terminated at will, with or without cause, and with or without notice, at any time, either at my option or the option of the company. I further understand that nothing in this application, or in any oral or written statement provided to me by Valley Regional Hospice will limit these rights to terminate my employment at will, and no representative of the company will have any authority to change this at-will relationship, unless such a change is authorized in writing and duly signed by the Mari Zakaryan, President of Valley Regional Hospice.

I understand that any offer of employment is conditioned on my providing satisfactory proof of my identity and proof of eligibility to work in the United States. I further understand that this application is only valid for the position applied for at present and that Valley Regional Hospice is under no obligation to retain or consider this application for any future openings.
Signature*
Please Print Name:*
Date:*
Date Format: MM slash DD slash YYYY
Number
Number
Comments
This field is for validation purposes and should be left unchanged.

II. Position

III. PERSONAL COMMENTS

IV. EDUCATIONAL BACKGROUND, MILITARY SERVICE, PROFESSIONAL POSITIONS, AND ADDITIONAL INFORMATION

V. EMPLOYMENT EXPERIENCE

VI. ACKNOWLEDGMENT AND SIGNATURE