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CALIFü R N I,q

iT::':T:T,i:f13ia'lion

APPLICAT¡ON FOR EMPLOYMENTAn Equal Opportunity Employer

INSTRUCTIONSCompletion of this form is part of the Agency's application process. All requested information must be written on the applicationform itself. Resumes or attachments may be included, but cannot be substituted for a completed application form. Failure tocomplete the application accurately may disqualify an individual from being considered for a position, or if hired, may result intermination of employment. Additionally, if the Agency extends you an offer of employment, it will be contingent upon: 1) yourpassing a pre-employment physical exam, which may include a drug screen, to verify your ability to perform essential jobfunctions, and 2) the Agency receiving satisfactory background and reference check information for you, which may include butnot be limited to verification of education and professional licensure, prior employment, criminal background check, MotorVehicle Record check, and proof of automobile insurance.

PeRsorunl lruroRumo¡rName {Last, First, M¡ddle) Today's Date (Month Day Year)

Address City, State Zip Code Social Security Number

Home Phone)

Work Phone( )

Cell Phone( )

E-Mail

No

trYesHave you previously been

employed by VNACalifornia (or VNAIC)?

Name while employed w/ VNA California (orvNArc)

Dates of previous VNA California(or VNAIC) employment

lf hired, when can you start?

you any an

Position applied for Full Time Part Time Per Diem Temp Hours desired (if applicable) Desired Salary (hourly rate)

Would you be willing to work overtime? Yes tr NonPerson to notify in case of emergency:

Number, Street / P.O. Box Zip Code

Last First

( )State Pho neCity

List any other name by which you have been known for the purpose of employment and licensure:

Professional California License(s) or Certification. Circle as applicable: PHN, RN, LCSW, OT, ST, RD, PT, PTA, LVN,HHA, Other:

Number: Expiration Date

Can you, after receiving an offer of employment, submit:Proof of your legal right to work in the U.S.?

Proof that you are at least 1B years of age?

n Yes

n Yes

nNotrNo

Have you ever been convicted of any crime other than a minor traffic violation?(A conviction is not an automatic bar to employment. Each case will be considered on its own merits.)

lf yes, please explain and state the charge, the court, the date and disposition of the case:

n Yes trNo

Are there any arrests or criminal proceedings currently pending against you? ! Yes tr No(A pending arrest or criminal proceeding is not an automatic bar to employment. Each case will be considered on its own merits.)

lf yes, please explain

8/2013

EuplovlvrEn¡r RecoRD FoR rne PRsr SEve¡¡ YenRs: Becr¡r wrrH youR Mosr REcENT EMpLoyER.DO NOT OMIT ANY EMPLOYMENT. (Attøch ø second sheet if necessury.l

Are you presently employed? tr Yes tr No May we contact your present employer? tr Yes ! No

Other names under which you have worked

Dates/Salary Information Gurrent Employer Your Job Title and DutiesFirm Name & AddressFrom

Mo YrTo

Mo Yr

Hours WorkedPer Week

SALARY Type of Business

Start me Reason for Leavìng

Last Supervisor's Phone #

Dates/Salary lnformation Previous Employer Your Job Title and DutiesFirm Name & AddressFrom

Mo YrTo

Mo Yr

Hours WorkedPer Week

SALARY Type of Business

Stari Reason for Leaving

Last Supervisor's Phone #

Dates/Salary lnformation Previous Employer Your Job Title and DutiesFirm Name & AddressFrom

Mo YrTo

Mo Yr

Hours WorkedPer Week

SALARY Type of Business

Start Name of Your lmmediate Supervisor Reason for Leaving

Last Supervisor's Phone #

Dates/Salary lnformation Previous Employer Your Job Title and DutiesF¡rm Name & AddressFrom

Mo YrTo

Mo Yr

Hours WorkedPer Week

SALARY Type of Business

Start Name of Your lmmed¡ate Superv¡sor Reason for Leaving

Last Supervisor's Phone #

List ANY periods of unemployment during the past seven years, beginning with the most recent period of unemployment

From To Reason for Unemployment

8t2013

Ge¡¡eR¡tDo you have a valid California's Driver's License? n Yes fl No License #

We are interested to know how you were referred to VNA California. Please check the appropriate areas below:

D Classified ad in Newspaper or Publication tr lnternet Posting or Website

Which One Which Site:

tr Job Fair

Which One:

tr Other:

tr Employee Referral

Name of Employee:

tr Direct mail postcard / flyer

EoucRnoHCollege

1234Graduate

1234Skills and Education (Circle highest grade completed)

123456789101112Degree orDiploma

GPA MajorSchool LocationFromMo Yr

ToMo Yr

No. of UnitsGompleted

What Hours? Course of Study?Are you attendingschool now?

Yesn

Notr

Where?

Cuucnl Sxru-sPlace an X in the boxes to indicate experience in the following

D Cardiac Cath Labtr Teaching/Supervisiontr tcu/ccu

tr Home Healthtr Hospicetr Med/Surg

tr Orthopedicsn Pediatricstr Respiratory

tr Special Proceduresn StudentPreceptorshiptr Telemetry

Are you certified in CPR/BLS? n Yes D No E ln Process

lf yes, expiration date

Are you certified in ACLS/PALS? tr Yes ! No n In Process

lf yes, expiration date

Other

Orr¡ce / Glenrcnl Srcl.l-sn Microsoft Office Suite

tr Wordtr Exceltr Accesstr PowerPointtr Publishern Outlook

n 1O-Key ! MedicalTerminology tr Medical Transcription

! Other Computer Applications:

tr Other Office Skills:

8t2013

Professional References (Please do not list relatives)

Name and Occupation Address, City, State, Zip Phone Number

Name and Address, City, State, Z¡p Phone Number

Selr DescRrPTroN

ln the space provided below, please describe yourself in your own words without any attempt to be modest, including

strengths and weaknesses that may affect your ability to succeed in the position for which you have applied. Why do you

think you are qualified for this position?

Goruorlorus oF EMPLoYMENT

I cerlify that the information in the employment application and any related document that I am submitting is correct to the best of my

tnowlédge. I understand that falsificaiion of this information is grounds for refusal to hire or, if hired, termination. I authorize any of the

p"rronsó, organizations noted in the application to give VNA California any and all information concerning my previous employment,

education, orãther information they might have, perõonal or otherwise, with regard to any of the subjects covered by the application. I

authorize VNA California to requesi anã receive such information and release VNA California and all such parties from all liability for any

damage that may result from furnishing such information to VNA California, its agents and representatives.

I agree that, if hired, I will follow the rules, regulations and policies of VNA California and acknowledge that these rules, regulations and

po[cies may be changed, interpreted, deleteã, or added to at any time without any prior notice to me. This may include, but is not limited to'

overtime, rotating or ðhanging work assignments, locations and schedules, drug testing, weekend and night work, and other conditions that

may not necessarily meet with my individual preference.

ln applying for employmeni with VNA California, I understand and agree that, if hired, my employment would not be for a definite term

ot pärióO õt t¡me, and would be at-will. I understand that under this at-will employment status I may be terminated at any-time without

any obligation on VNA California's parl to provide cause or justification. By accepting employment, if offered, with VNA California, I agree to

tfr¡å at-wìll employment status. Finälly, I understand that any offer of employment will be based on, among other things, my signing a written

ACKNOWLEDGMENT agreeing that my employment is at-will.

I further agree that my employment, if offered, may be subject to a physical examination, which may include a drug screen, to determine if I

am physicãlly and otherwise iit to perform the essential functions for the position for which I am being considered. I hereby agree that the

results of this physical examination shall be released to representatives of VNA California.

I understand that proof of identity and lawful status to work in the United States is also required as a condition of any offered employment'

I acknowledge and agree that my employment with VNA California may require that I use my own vehicle for transportation to and from

assignmentJ. I agree to furnish úruR Calitornia with a copy of my automobile insurance. Applicants whose jobs require driving must have a

driver's license vãtid ¡n California and are subject to a Department of Motor Vehicles check prior to employment and as a basis of continued

employment. I agree with and consent to all of the above as VNA California considers me for employment.

Date Signature

APPLICATIONS ARE CONSIDERED INCOMPLETE WITHOUT A DATED SIGNATURE.VNA California is an equal opporlunity employer and is committed to making hiring and other employment related decisions without regard

to an individual's race, color, creed, sex, sexual orientation, national origin, ancestry, citizenship, age, handicap or disability (including

pregnancy), medical condition, religion, marital status, or any other legally protected status.

812013

t #

Visiting N urse Association'HOME HEALTH. HOSPICE, OUTREACH.

TO: Whom it May Concern DATE:

FROM:Name Social Security Number

I have applied for a position with \rNA Califomia

I hereby authorize you, and any of your officers and employees, to disclose to VNA California,any and all information in your possession peftaining in any way to me or to my employmentwith you. I recognize that this authorization may cause both favorable and unfavorableinformation which may be obtained in my personnel file to be released. Nevertheless, I desirethat all such information be disclosed and I hereby release you, your officers and employeesfrom any and all liability for damages resulting directly or indirectly from such disclosure.

Thank you in advance for your cooperation.

Yours truly,

Signature

EMPLOYERS, PLEASE NOTE:

SECTION 47 OF THE CALIFORNIA CIVI CODE GRANTS PROTECTION FROM TORTLIABILITY TO CALIFORNIA EMPLOYERS WHO PROVIDE REFERENCES UPONREQUEST TO OTHER EMPLOYERS ABOUT PROSPECTIVE EMPLOYEES.

YOUR PARTICIPATION IN THIS VERIFICATION PROCESS WILL BE CONSIDEREDSTRICTLY CONFIDENTIAL, AND WILL BE MUCH APPRECIATED.

VNA CALIFORNIA - ADMINISTRATIVE CENTER6235 River Crest Drive, Suite L, Riverside, Catifornia 92507Tetephone 95L- 4I3 - 1"200 I t ax 95I- 413 - l2OB

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L¿\L1¡Uiilli¡r,'lr*tr1 iry]r:t$:v:d{Ð APPLICANT SELF-IDENTIFICATION FORM

VNA Califomia is an Equal Opportunity Employer and complies with all applicable regulations. We are required tosolicit the information indicated below for statistical reporting putposes.

Your responses are voluntary and your cooperation in providing this information is appreciated.

Position Applied for Date

Gender: n uut"n Female

City of Residence Age

Ethnic Origìn (Select All Thøt Apply):n Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish

culture or oligin, regardless of race.

n Wnite A person having origins in any of the original peoples of Europe, the Middle East or NorlhAflica.

fl gtact or Äfrican American A person having origins in any of the black racial groups of Africa.

fl Nutin" Hawaiian or Other A person having origins in any of the original peoples of Hawaii, Guam, Satnoa

Pacific Islander ol othq Pacilìc Islands.

nArion A person having oligins in any of the original peoples of the Far East, Southeast Asia, or

the Indian subcontinent including, for example, Carnbodia,China, India, Japan, Korea,

r Ämerican rndia' or A,aska Ti'3J:#iiïff,o,T':ïiîJ,i""Ji,;iTäiÏ"i'fftr'l¿ so,,r,Native America (including Central America), and who maintaíns tribal affrliation or community

attachlnent.

n ttno or more races A person who identifies with more than one of the above five races.

Disabílíty: Do yott belìeve you are a qualìjìed índividual with a disabilÍty, subject to the benefits of the

Rehab Act, the Americans wìth Dísabílities Act, or Califurnia's Fair Employment and Housittg Act?fl y., fl No

If yes, and you feel you need reasonable accommodation, please give details:

Veterun Status: Do you belìeve you øre a veterøn subject to the benefits of one or more of tlrc qualffiedcovered veteran categories?I Nla Not a veteran.

n Disabled Veteran (i) A veteran of U.S. militaly, ground, naval or air service who is entitled to cornpensation(or who but for the receipt of rnilitary retired pay would be entitled to cornpensation)undel laws adlninisteled by the Secretaly of Veteran Affairs, or (iì) a person who was

discharged ol released fi'om active duty because of service connected disability.

n Otn"r Protected Veteran A veteran who sei-ved on active duty in the U.S. rnilitary, glound, naval or ail'seliceduring a war or in a carnpaign or expedition for which a campaign badge has been

authorized.

X,{rmed Forces Service A vetetan who, while selving on active duty in the U.S. military, ground, naval, or

Medal Veteran air service, participated in the U.S. rnilitary opelation for which an Atmed Forces

I Recently separated veteran î'Jå;ïl'îj'J':ät":ïre'iod beginning on the date orsuch veteran's discharge

ot release frorn active duty in the U.S rnilitary, ground, naval or air service.

How díd youfirst learn of employment opportun¡ties wìth tlús Agency?n Internet Posting: V/hich site?

-

n uve website

n Newspaper/ Bulletin: Which one?

! Friend:Who?

n Posted Amouncement: Where?

Other: Please

fl vN¿. employee: Who?-E r¡Na Billboard: Where?

n Cu.""r Publication: Which one?

I School: Which one'/

SignatureRevised 08113/12

CALIFüR N IAVisiting N ursê Assüc¡åt¡tlrl!,i 1\ì, j i, ir; !, : a.:: :' ):.. a i:r.j\,i :,:..1 t

VNA California conducts criminal background checks of all staff and volunteer applicants. We are contracted

with Pre-Ernploy.com to accomplish that check. Following is information provided by Pre-Ernploy.comregarding the background check process, and the disclosure of information needed to conduct the check.

PLEASE READ CAREFULLY

DISCLOSURE AND AUTHORIZATION FORM

Pre-employ.com will procure a consumer repoft and/or investigative consumer repoft on you in connection with youremployment application. Pre-employ.com, Inc., or another consumer reporling agency, will obtain the reporl for VNACalifornia. Pre-employ.com, Inc is located at 230I Balls Ferry Rd, Anderson, CA 96007 and can be reached at 800-300-1821.

The report will contain information bearing on youl character, general reputation, personal characteristics, mode of livingand credit standing. The types of information that may be obtained include but are not limited to: credit reports, socialsecurity number verification, criminal records checks, public couft records checks, driving records checks, educationalrecords checks, verif,rcation of employment positions held, personal and professional references checks, licensing and

ceftification checks, etc. The information contained in the report will be obtained from private and/or public recordsources, including sources identified by you or through interviews or coffespondence with your past or present coworkers,neighbors, friends, associates, current or former employers, educational institutions or other acquaintances.

The nature and scope of any investigative consumer repods that may be requested is explained above. You are

nonetheless entitled to request more information about the nature and scope of such reports by submitting a writtenrequest to: Compliance Department, P.O. Box 491570, Redding, CA96049 or faxed to 888-999-3839.

A summary of your rights under the Fair Credit Reporling Act is available by visiting www,ftc.sov/credít You may also

write to the FTC Consumer Response Center, Room 130-4, 600 Pennsylvania Ave, N.W., Washington, D.C. 20580.

Para ínþrntacion en espanol, visite www.ftc.gov/çredit o escribe ø la FTC Consumer Response Center, Room 130-A

600 Perursylvania Ave,, N.l/'., Washington, D,C, 2058.

ADDITIONAL STATE LAW NOTICES

Because you live or are applying for a job in the state of California, please review these additional notices

CALIFORNXA: You may view the file maintained on you by Pre-employ.com,Inc. You may also obtain a copy of thisfile, upon submitting proper identif,rcation and paying the costs of duplication services, by appearing at Pre-employ.com,Inc. offices in person, during normal business hours and on reasonable notice, or by mail; you may also receive a

sulnmary of the file by telephone. Fre-employ.com, Inc. has trained personnel available to explain your file to you,

including any coded information. If you appear in person, you may be accompanied by one other person, provided thatperson furnishes proper identification.

ffi

AUTHORIZATION

I have carefully read and understand this Disclosure and Authorization fonn. By my signature below, I consent to therelease of reporls prepared by a consumer reporting agency, such as Pre-employ.com, Inc., to VNA California. Iunderstand that if VNA California hires me, my consent will apply throughout rny employment unless I revoke or cancelit by sendirig a signed letter to Compliance Department, P.O. Box 491570, Redding, CA 96049 or faxed to 888-999-3839.

I understand that, to the extent allowed by law, information contained in my job application or otherwise disclosed by mebefore, during or after my employment, if any, may be utilized for the purpose of obtaining criminal background repofts.

By my signature below, I also authorize the disclosure of information concerning my criminal history, and all otherinformation deemed pertinent by the consumer reporting agency, to the agency by the following: past or present

employers; law enforcement agencies; federal, state and local courts; and the military.

f,'or residents of, or for jobs located in California: You will be provided with a free copy of any reports if you checkthe box below. You may obtain information or copies from the Company's file at any time prior to your receipt of suchcopies, to the extent available, by contacting Compliance Department, P.O. Box 491570, Redding, CL 6049 or by tollfree fax 888-999-3839.

I request a free copy ofthe report. n

Occasionally, Pre-employ.com and/ or its partners send information on identity theft protection, background checkinformation and other related products or services.

I DO or I DO NOT wish to receive this information via email or mail.

Signature: Date:

FirstName: Last Middle

List all other names used in the last 7 years

Date of Birth Social Security Number:

Drivers License Number: State issued

Current Address

City: State: zip

Address Historv - Please list the city, state, atd zip you have lived or worked in for the past 7 years with approximate dates

Dates: City: State: zip

City: State:Dates: zip

Dates: City: State: zlp

Daytime phone number: ( ) Email Address:

The information is for identification es Please rint clea in Black Ink!

***** APPLICANT _ DO NOT WRITE BELOW THIS LINE *****

Company ID:

t7t83

PO#Company Name:

Visitinq Nurse Association of the Inland Counties dba VNA California

Please indicate the services you would like to request for this applicant.Fax this sheet to 888-999-3839 or enter the information at https://www.Dre-emnlov.com

Basic Services Requested:

VNAIC Basic Packase: Social Security Velification/Locatot'and climinal backqround check in all counties lived and wotked in the last 3 - 7 veals.

Purø informacíon en espünol, vßite www.ftc.gov/credít o escribe u la FTC Consumer ResponseCenter, Room 130-A 600 Perutsylvønia Ave., N.lí/., úI/øslúngton, D.C. 20580

A. SumuaRy oF YouR Rrcnrs{JNopnrnn FarR CRnrrr RnpoRrrNG Acr

The federal Fair Cledit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information inthe files of consumer reporting agencies. There are many types of consumer repofting agencies, includingcredit bureaus and specialty agencies (such as agencies that sell information about check writing histories,medical recolds, and rental history records). Hele is a summary of your major rights under the FCRA. Formore information, including information about additional rights, go to www.ftcgov/credit or write to:Consumer Response Center, Room 130-4, Federal Trade Commission, 600 Pennsylvania Ave. N.W.,Washington, D.C. 20580.

tr You must be told Íf information in your file has been used against you. Anyone who uses acredit report or another type of collsulner report'to deny youl application for credit, insurance, oremployrnent - or to take another adverse action against you -- must tell you, and must give you thenarne, address, and phone number of the agency that provided the information.

tr You have the right to know what is in your fïle. You may request and obtain all the informatiouabout you in the files of a consumer reporting agency (your "file disclosure"). You will berequired to plovide proper identification, which rnay include your Social Security number. Inrrìarly cases, tlie disclosure will be free. You are entitled to a free file disclosure if:

tr a person has taken adverse action against you because of information in your credit report;

o you are the victim of identity theft and place a fraud alert in your file;

tr your file contains inaccurate information as a result of fi'aud;

a you are on public assistance;

ü you are unernployed but expect to apply for employrnent within 60 days.

In addition, by Septernber 2005 all consumers will be entitled to one free disclosure every 12

months uporl request from eaclr nationwide credit bureau and from nationwide specialty consuilìerleporting agencies. See www.ftc. gov/ credit for additional information.

tr You have the right to ask for a credit score. Credit scores are numerical summaries of yourcredit-wortliiness based on infornation fi'om credit bureaus. You may request a credit score fromconsurnel'reporting agencies that create scores or distribute scor'es used in residential real propertyloans, but you will have to pay for it. In some rnortgage transactions, you will receive credit scoreinfomration for fi'ee from the mortgage lender.

tr You have the right to dispute incomplete or inaccurate information. If you identi$'information in your file that is incomplete or inaccurate, and repoft it to the consulner reportingagency, the agency must investigate unless your dispute is frivolous. See www.ftc.qov/creditfor an explanation ofdispute procedures.

tr Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiableinformation. Inaccurate, incomplete or unverifiable information must be removed or corrected,usually within 30 days. However, a consunler ageÍìcy may continue to report information it hasverified as accurate.

tr Consumer reporting agencies may not reporf outdated negative information. In most cases, a

consumer reporting agency may not report negative information that is more than seven years old,or banlcruptcies that are rnore tlian 10 years old.

tr Access to your file is limited. A consumer reporting agelìcy rnay plovide infonnation about you

o¡ly to people rvith a valid need - usually to consider an application with a creditor, iusurer,

employer, landlord, or other business. The FCRA specifies those with a valid ueed for access'

tr You must give your consent for reports to be provided to employers. A cousutner reporting

agency may not give out inforrnation about you to your employer, or a potential employer, without

yóur writteu consent given to the employer. Wlitten consent generally is uot requiled in the

trucking industry. For more information, go to www.ftc.gov/cledit.

tr You may limit ,,prescreened" offers of credit ancl insurance you get based on information in

your credit r.poit. Unsolicited "prescreened" offers for credit and insurance lnust include a toll-

iree phone number you can call if you choose to rernove yolìr name and addt'ess frorn the lists

these offers are based on. You may opt-out with the nationwide credit bureaus.

tr You may seek damages from violators. If a consutner lepofting agency, or, itt sotne cases, a user

of consumer reports or a furnisher of information to a cotlsttmer reporting agellcy violates the

FCRA, you may be able to sue in state or federal cout't.

D Identify theft victims and active duty military personnel have additional rights. For rnore

information, visit www.ftc. gov/ cledit.

States may enforce the FCRA, and many states have their own consumer reporting laws. Insome cases, you may have more rights under state larv. For more inforrnation, contact your state

or local consumer protection agency or your state Attorney General. Federal enforcers al"e:

PLEASE CONTACT:TYPE OF BUSINESS:

I Trade Commission: Consumer Response Center -

ashin DC 20580 l-877 -382-43s7

Consumer reporting agencies, creditors and others

not listed below

Office of the Comptroller of the CurrencyCompliance Management, Mail Stop 6-6

,DC20219 800-613-6743Wash

ational banks, federal branches/agencies of foreignnks (word "National" or initials "N.4." appear in

or after bank's name

ivision of Consumer & Community Affairsaslrington, DC 20551 202'452-3693

ederal Reserve BoardFederal Reserve System member banks (except

national banks, and federal branches/agencies offoreign banks)

Offïce of Thrift SupervisionConsumer Complaints

DC 20552 800-842-6929Washington,

Savings associations and federally chartered savings

banhs (word "Federal" or initials *F.S.B.t' appear infederal institution's name)

Federal credit unions (words "Federal Credit Union"appear in institution's name)

National Credit Union Administration775 Duke Street

vA223t4 703-519-4600

I Deposit Insurance Corporation

nsas City, Missouri 64108-2638t-8'77-275-3342

Grand Avenue, Suite 100er Response Center

ent of Transportation, OffTce of Financial

, Ðc 20590 202-366-1306WashManagement

surfaceo or rail common carriers regulated byformer Civil Aeronautics Board or InterstateCommerce Commission

artered banks that are not members of theReserve System

of Deputy Administrator- GIFSA720-1051202-

of AgricultureActivities subject to the Fackers and Stockyards Act,t92l