Application form

Fill out the online form below or download our pdf application form, which you can print and mail.

Vernon Advent Christian Home does not discriminate in hiring or in any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

Title of job applied for:
Date:
Full Name:
Social Security Number:
Mailing Address:
City, State, Zip Code:
Home Phone:
Work Phone:

E-mail address:

 


Yes
No
 Statements (Check either "Yes or No" for each question)
Are you 18 years of age or older?
    If not, birth date:
Have you previously been employed by Vernon Advent Christian Home?
If yes, when?

Supervisor:

Reason for leaving:
Do you have any relative or any other person(s) residing with you, who is employed by Vernon Advent Christian Home?
If yes, Name:

Relationship:
Have you been convicted of a crime?
Position Interest / Availability
Check the type(s) of employment you are interested in:
Full-Time Part-Time Temporary All
Do you have reliable transportation? Yes No
Anticipated rate of pay:
$ per hour
How did you hear about employment at Vernon Advent Christian Home?

What are the two most important factors to you in choosing a job?
1.

2.

Check the shifts you are willing to work:
Day Shift Evening Shift Night Shift Any Shift
How many miles away do you live?
Date you are available?
Why have you considered employment at Vernon Advent Christian Home?
Did a current employee refer you to us? Yes No
Employee's Name
For employment, can you submit verification of U.S. Citizenship, Permanent Resident, or Registered Alien? Yes No
If alien, Alien Registration Number:
Expiration Date:
Education/Training History
Name and location of last school attended:
Dates Attended:
Fields of Study (major, minor):
Highest Grade Completed:
Degree Earned and Year:
Yes No Do you have a high school diploma or GED certificate?
Yes No Are you currently enrolled in a course of study?
What?

Where?
Professional License
Description (e.g.Registered Nurse):
License Number:
State:
Expiration Date:
Personal References
Please list three individuals not related to you who may know of your work qualifications and can serve as a reference for you.
Name and Title or Relationship:
Full Address: Phone:
Name and Title or Relationship:
Full Address: Phone:
Name and Title or Relationship:
Full Address: Phone:
Employer 1
Job Title: Employer:
Type of Business: Address:
Phone #: Employment from, to:
Starting hourly pay: Ending hourly pay:
Supervisor's name: Duties:
Reasons for leaving: May we contact this employer?:
Yes No
Employer 2
Job Title: Employer:
Type of Business: Address:
Phone #: Employment from, to:
Starting hourly pay: Ending hourly pay:
Supervisor's name: Duties:
Reasons for leaving: May we contact this employer?:
Yes No
Employer 3
Job Title: Employer:
Type of Business: Address:
Phone #: Employment from, to:
Starting hourly pay: Ending hourly pay:
Supervisor's name: Duties:
Reasons for leaving: May we contact this employer?:
Yes No

I voluntarily give Vernon Advent Christian Home the right to make a thorough investigation of my past employment and activities. I agree to cooperate in such investigation including the release of information from my personnel files of former or current employers. I do release from all liability or responsibility all persons, companies or corporations supplying such information.

I understand, if hired, my employment will be terminated if information obtained from background investigations substantiates a finding of abuse, neglect, exploitation, and/or criminal activities.

I understand that my employment is dependent upon satisfactorily passing a physical exam thirty days prior to the date of hire or within thirty days from date of hire. I also understand that employment is dependent upon satisfactorily passing future physical examinations, which relate to the essential duties I would be required to perform, as may be required by Vernon Advent Christian Home at such times and places as the institution shall designate.

I understand that my employment is at-will and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If accepted for employment, I will read the Employee Handbook and comply with Vernon Advent Christian Home’s policies and will complete an Employment Verification Form (I-9) and show satisfactory evidence of identity and eligibility for employment

Name: Date:


Vernon Advent Christian Home Statement of Values
We will create "A community of caring that you can call home" by:

 

How to contact us:
Phone: 802-254-6041
Fax: 802-257-5362
E-mail: coleen@vernonhome.org
Address:

Coleen Williams
Vernon Advent Christian Home
61 Greenway Drive
Vernon, VT 05354

 

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