Application form

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

Vernon Advent Christian Home is an equal opportunity employer and is firmly committed to prohibiting discrimination throughout the employment process against individuals because of race, color, sex, sexual orientation, gender identity, age, religion, national origin, ancestry, place of birth, military status, positive HIV-related blood test, or against qualified individuals with disabilities, or because of any other legally protected status.

Title of job applied for:
Date:
Full Name (Last,MI, First:
Social Security Number:
Mailing Address:
City, State, Zip Code:
Permanent Address (if different from mailing):
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?
If yes provide explanation with dates
Position Interest / Availability
Check the type(s) of employment you are interested in:
Full-Time Part-Time Temporary All
Check the shifts you are willing to work:
Day Shift Night Shift Evening Shift Any Shift
Do you have reliable transportation? Yes No
How many miles away do you live?
Anticipated rate of pay:
$ per hour
How did you hear about employment at Vernon Advent Christian Home?
Why have you considered employment at Vernon Advent Christian Home?

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

2.

Date you are available?
Did a current employee refer you to us? Yes No
Employee's Name
Are you legally eligible for work in the United States Yes No

Can you provide appropriate documentation?: Yes No
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?

Employment History

A resume will not substitute for the following information. List employment starting with your current or most recent position; include service in the U.S. military, if applicable. Account for any time during this period that you were unemployed by stating the nature of your activities.
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
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:

In submitting this application,

  • I authorize Vernon to thoroughly investigate my employment history and activities. I agree to cooperate in such investigation, including the release of information from my personnel files of former or current employers. I release from all liability or responsibility all persons, companies or corporations supplying such information.
  • I understand that an offer of employment is contingent upon a satisfactory background check, which includes checks of the state child abuse registry, state adult abuse registry, 50 state criminal registry, the Office of Inspector General, and if applicable, the Department of Motor Vehicles. I further understand that background checks will be conducted on a regular basis throughout any period of employment with Vernon Advent Christian Home.
  • I understand that an offer of employment is contingent upon my satisfactorily passing a physical examination before date of hire.
  • I understand and agree that employment with Vernon Advent Christian Home is at-will, which means either party is free to terminate the employment relationship at any time for any reason or for no reason.
  • I certify that statements made on this application and attachments (if any) and/or during the interview process are true and complete and that nothing has been withheld that would affect this application. I further understand that any false statement will result in rejection of this application, and if employed, dismissal.

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

Employment Application 11/09

Vernon Advent Christian Home, Inc., 61 Greenway Drive, Vernon, Vermont   05354

Telephone # 802-254-6041 Fax # 802-257-5362

 

 

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