Apply Online

Section 1: Personal Information

How did you learn about us?*

Emergency Contact:

Have you ever filed an application with us before?*

Have you ever been employed with us before?*

Are you currently employed?*

May we contact your present employer?

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status? Note: Proof of citizenship or immigration status will be required upon employment.*

Are you available to work:

Are you currently on "lay-off" status and subject to recall?*

Section 2: Resume and Other Documents


Section 3: Education and Employment Experience

Can you travel if a job requires it?*


High School

Undergraduate College

Graduate Professional

Other (Please Specify)

Section 4: Employment Experience

Employment Experience

Please start with your present or last job and include any job-related military service assignments and volunteer activities. You may exclude organizations, which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer 1*:

Dates Employed:


Hourly Rate/Salary*:


Employer 2:

Dates Employed:


Hourly Rate/Salary:


Employer 3:

Dates Employed:


Hourly Rate/Salary:


Employer 4:

Dates Employed:


Hourly Rate/Salary:


Please list professional, trade business or civic activities and offices held. You may exclude organizations, which indicate race, religion, gender, national origin, disabilities or other protected status.

Section 5: Electronic Signature of Applicant

Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless other wise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.


Reference 1

Reference 2

Consent and Release Form

I hereby authorize, without reservation, VNA to conduct all background checks, and reference checks, and a drug screening.

I understand that my refusal to authorize VNA to conduct these checks, may result in the revocation of any offer of employment that I have received and my exclusion from consideration for future employment with VNA. Thus, I hereby release VNA as well as the consumer reporting agency or any other entity retained to provide information regarding my background, its officers, employees or agents, parent companies, subsidiaries, affiliates, from all claims, suits, actions and judgements resulting from or arising out of the background check either directly or indirectly.

We will need a copy of your New Jersey Driver’s License and your Social Security number.

As part of our employment procedure, for all prospective employees extended an offer of employment, the Visiting Nurse Association of Somerset Hills (VNA) will conduct a state criminal background check and a DMV driver’s record check. VNA will also send all prospective employees to a designated Diagnostics Lab to collect a urine sample to screen for illicit substance within 48 hours of job offer.

For all Healthcare Professionals, VNA complies with the NJ Healthcare Professional Responsibility and Reporting Enhancement Act in obtaining information regarding past job performance, conduct and competence.

VNA will use the information obtained for employment purposes only.

To authorize VNA to conduct these checks, please sign the Consent and Release Form provided below.

NOTE: If you do not authorize VNA to conduct a background check and/or a drug
screening, VNA is entitled under law to refuse to consider you for hire.

Voluntary Self-Identification Information

Completion of this form is voluntary and is not a requirement of employment. This information will in no way affect the decision regarding your application for employment. This information will be kept confidential. We hope that you will complete this form to assist us in recording information for statistical reports that we are obliged to file periodically with various government agencies.



 Hispanic or Latino Not Hispanic or Latino


Veteran Status: