APPLICATION FOR EMPLOYMENTFederal and State laws prohibit discrimination in employment because of sex, race, creed, religion, national origin, age, handicap, marital status, status with regard to public assistance or veterans employment. We are an equal opportunity employer.PERSONAL INFORMATIONDateSelect a dateField is required!Field is required! Last NameYour: First Name /Middle Name:Field is required!Field is required! First NameYour: First Name /Middle Name:Field is required!Field is required! Middle NameYour: First Name /Middle Name:Field is required!Field is required!Social Security #Social Security #Field is required!Field is required!Other surnames that I have usedYour Full NameField is required!Field is required!Present_AddressPresent_Address: Street/City/State/ZipField is required!Field is required!Permanent_AddressPermanent Address: Street/City/State/ZipField is required!Field is required!Home_PhoneHome_PhoneInvalid phonenumber!Invalid phonenumber!Alternate Phone #:Your PhonenumberInvalid phonenumber!Invalid phonenumber!How did you hear about this position?How_did_you_hear_about_this_position?Field is required!Field is required!Referred By:Referred By:Field is required!Field is required!YESNOField is required!Field is required!Are you at least 8 years of ageYESNOField is required!Field is required!Have you passed Competency Testing?YESNOField is required!Field is required!U S Military or Naval ServiceU.S. Military or Naval Service Rank:Field is required!Field is required!Present Membership in National Guard or Reserves?YESNOField is required!Field is required!EMPLOYMENT DESIREDPosition:Home Health AideHomemakerLPN/LVNRNStaffingClericalPersonal Care AttendantOtherField is required!Field is required!Have you passed Competency Testing?YESNOField is required!Field is required!Do you have a Certificate?YESNOField is required!Field is required!Do you have a current Driver’s License?YESNOField is required!Field is required!Do you currently have a car?YESNOField is required!Field is required!REFERENCESGive below the names of three work related referencesHave you ever applied to this Company before?YESNOField is required!Field is required!PROFESSIONAL LICENSES, CERTIFICATION, AND REGISTRATIONSDo you have any professional licenses, certifications and/or registrations?YESNOField is required!Field is required!License/Certificate/ Registration #:License/Certificate/ Registration #:Field is required!Field is required!TypeTypeField is required!Field is required!State IssuedState IssuedField is required!Field is required!Date ExpiresDate ExpiresField is required!Field is required!Status (List Active, Inactive, Restricted, Conditional or Pending)Status (List Active, Inactive, Restricted, Conditional or Pending)Field is required!Field is required!REFERENCESGive below the names of three work related referencesNAMENAMEField is required!Field is required!NAMENAMEField is required!Field is required!ADDRESSADDRESSField is required!Field is required!ADDRESSADDRESSField is required!Field is required!COMPANY/POSITIONCOMPANY/POSITIONField is required!Field is required!COMPANY/POSITIONCOMPANY/POSITIONField is required!Field is required!NAMENAMEField is required!Field is required!NAMENAMEField is required!Field is required!EDUCATIONNAMENAME Field is required!Field is required!NAMENAME Field is required!Field is required!LOCATION OF SCHOOLLOCATION OF SCHOOLField is required!Field is required!LOCATION OF SCHOOLLOCATION OF SCHOOLField is required!Field is required!YEARS ATTENDEDYEARS ATTENDEDField is required!Field is required!YEARS ATTENDEDYEARS ATTENDEDField is required!Field is required!GRADUATEDGRADUATEDField is required!Field is required!YesNoField is required!Field is required!DEGREE/CERTIFICATIONDEGREE/CERTIFICATIONField is required!Field is required!GRADUATEDGRADUATEDField is required!Field is required!FORMER EMPLOYERSList below your complete employment history for the last five years, starting with the most recent position first. Attach additional pages if necessary.DATE MONTH AND YEARDATE MONTH AND YEARField is required!Field is required!DATE MONTH AND YEARDATE MONTH AND YEARField is required!Field is required!NAME AND ADDRESS OF EMPLOYER SUPERVISOR'S NAMENAME AND ADDRESS OF EMPLOYER SUPERVISOR'S NAMEField is required!Field is required!NAME /ADDRESS OF EMPLOYER SUPERVISOR'S NAMENAME/ ADDRESS OF EMPLOYER SUPERVISOR'S NAMEField is required!Field is required!May we contact?YESNOField is required!Field is required!SALARYSALARYField is required!Field is required!SALARYSALARYField is required!Field is required!POSITIONPOSITIONField is required!Field is required!POSITIONPOSITIONField is required!Field is required!REASON FOR LEAVINGREASON FOR LEAVINGField is required!Field is required!REASON FOR LEAVINGREASON FOR LEAVINGField is required!Field is required!I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for rejection or dismissal. Further, I understand and agree that 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, with or without cause, and with or without any prior notice.DateDateField is required!Field is required!SignatureField is required!Field is required!BRIGHT VISION HEALTHCARE LLCVOLUNTARY SELF-IDENTIFICATION INFORMATIONBRIGHT VISION HEALTHCARE LLC is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to sex, race, color, national origin or ancestry, age, handicap, marital status, source of income, class, physical characteristics, sexual orientation or political beliefs.As an employer, we comply with government regulations and affirmative action responsibilities. Solely to help us comply with government record keeping, reporting and other legal requirements, please complete this Voluntary Self-Identification Information form. This data is for analysis and affirmative action only and submission of this information is voluntary. This data will be kept in a confidential file separate from your Application for Employment.Date:Select a dateField is required!Field is required!Position Applied ForPosition Applied ForField is required!Field is required!Gender:MaleFemaleChoose not to respondField is required!Field is required!Race/Ethnic Background:American Indian / Alaskan NativeAsianNative Hawaiian/ Other Pacific IslanderBlack / African or African AmericanHispanic / LatinoWhite / CaucasianTwo or More RacesChoose not to respondField is required!Field is required!Veteran Status:Vietnam era veteranDisabled veteranOther veteranNon-veteranChoose not to respondField is required!Field is required!Disability Status*:* According to the American with Disabilities Act, the term “disability” means, with respect to an individual, a physical or mental impairment that substantially limits one or more of the major life activities of that individual, a record of such an impairment, or being regarded as having such an impairment.DisabledNot disabledChoose not to respondField is required!Field is required!Submit
