CNA and CHHA Jobs in Mercer & Burlington County, NJ | Visiting Angels

Referred By
Personal Data
Name*
FirstLast
Address*
Street AddressCityStateZip Code
Primary Phone*
Other Phone
Email*
How did you hear about us?*
- NJSeniorCare.com
- VisitingAngels.com
- Craig's List
- NJ Jobs
- Google Search
- Bing Search
- Postcard
- Unemployment Office
- Job Fair
- School Recruitment
- Place of Worship
- Community Organization
- TV Commercials
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- Walk-In
- Visitng Angel Employee
- Friend/Relative
- Other
If "Visiting Angels Employee," who?*
If "Friend/Relative," who?*
If "Other" please describe*
Foreign Languages Spoken (up to 3)
If "none" leave blank
Language A
Level of Fluency - Language A*
- Total Fluency
- Good
- A Little
Language B
Level of Fluency - Language B*
- Total Fluency
- Good
- A Little
Language C
Level of Fluency - Language C*
- Total Fluency
- Good
- A Little

Experience - Present or Most Recent Employer
Please give accurate and complete information. Start with present or most recent employer, including self-employment, part-time work, military employment, and any work performed on a volunteer basis.
Present/Most recent employer name*
Address*
Street AddressCityStateZip Code
Phone*
Name of Supervisor*
Your Job Title*
Employment Dates (From/To)*
Pay or Salary History (Starting/Ending)*
Reason for leaving or applying for a second job (be specific)*
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here.*
May we contact your present employer for a reference?*
- No
- Yes
If "No," please explain why and provide us with another work reference.

Previous Employer 1
Previous Employer Name
Supervisor's Name
Address
Street AddressCityStateZip Code
Employer's Phone
Employment Dates (From/To)
Pay or Salary History (Starting/Ending)
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here.

Previous Employer 2
Previous Employer Name
Supervisor's Name
Address
Street AddressCityStateZip Code
Employer's Phone
Employment Dates (From/To)
Pay or Salary History (Starting/Ending)
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here.

Education
Highest Level of education achieved*
- Elementary
- High School
- Community College Degree
- College Degree
- Advanced Degree
Please list the degree(s) earned
Please list any licenses or certification you currently hold.
Name & Address of School
Graduation Date
License or Certification Name
License or Certification Number
Date License Received
License Expiration Date
In what year did you first work as a CHHA or CNA?
Are you dual-certified (CHHA & CNA)?
May we contact schools you attended to verify the above information?

Legal History
Have you ever been charged of any crime?*
- No
- Yes
If yes, please describe*
Have you ever taken any money or property from an employer or client without permission?*
- No
- Yes
If yes, provide details*
Are you legally authorized to work in the U.S.?*
- No
- Yes
Have you ever worked under a different name?*
- No
- Yes
If yes, when was it and what was the reason?*

Emergency Contact Information
In case of emergency, please contact:
Name*
FirstLast
Primary Phone*
Secondary Phone
Work Phone
Relationship*
Second Emergency Contact
Name*
FirstLast
Primary Phone*
Secondary Phone
Work Phone
Relationship*

DISCLOSURE AND ACKNOWLEDGEMENT
Important - please read carefully before checking I Agree below.
Notice regarding background investigation

Visiting Angels may obtain information about you from a background screening company for employment purposes. These reports may contain information regarding your criminal history, social security verification, motor vehicle records ("driving records"), verification of your education or employment history, or other background checks. The scope of this notice and authorization is all-encompassing, however, allowing Visiting Angels to obtain from any outside organization all manner of background reports now and throughout the course of your employment to the extent permitted by law.

Certification and Release

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE, AND COMPLETE. I understand that any false information, omissions or misrepresentation of facts will result in rejection of this application and/or my termination at any time during employment. I authoirize Visiting Angels to verify any and all information contained within this application, including, but not limited to, criminal history and motor vehicle records. I authoirize Visiting Angels to contact all persons, schools, companies, and law enforcement authorities for the release of any information concerning my background & hereby release any said persons, schools, companies & law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of alcohol and/or illegal drugs is prohibited during employment and that I am willing to submit to alcohol and/or drug testing at any time to detect the use of alcohol and/or illegal drugs prior to or during employment.
By checking "I Agree," I acknowledge and agree to the preceding statement.*
- I Agree
Restrictive Covenant
I agree not to do business directly with any client, facility, or other business that Visiting Angels has introduced to me or by entering into employment with such individuals or businesses.*
- I Agree
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609-883-8188 | Email: info@njseniorcare.com

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Personal Data

Employment Desired

Experience - Present or Most Recent Employer

Previous Employer 1

Previous Employer 2

Education

Skills & Qualifications

Transportation

Legal History

Emergency Contact Information

Second Emergency Contact

DISCLOSURE AND ACKNOWLEDGEMENT

Notice regarding background investigation

Certification and Release

Restrictive Covenant