VEMA Job Application

Name

Application Date

Date of Birth

Address

Phone

Email

SSN

Emergency Contact Info

Emergency Contact Phone

Emergency Contact Address

Availability

Shifts

Work Days

Do you agree to work weekends/holidays in accordance with work schedules?

Yes No

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1. Are you legally authorized to work in the United States?

Yes No

2. Do you have a current TB Test?

Yes No

3. Do you currently have a valid driver's license?

Yes No

4. Do you have a current Fingerprint Clearance Card?

Yes No

5. Do you have a current CPR/First-Aid/Prevention & Support/Article 9?

Yes No

Specify:

6. Do you have your Caregiver Certification?

Yes No

7. Do you have your Direct Care Worker Certification (DCW)?

Yes No

8. Have you applied here before?

Yes No

9. Have you ever been employed by VEMA Corporation? If yes, when?

Yes No

9a. Dates employed by VEMA Corporation:

10. Have you ever been convicted of a crime or pleaded no contest for any offense or violation other than minor traffic violations? (Convictions are not an automatic bar to employment)

Yes No

11. Do you have any pending criminal charges against you? If yes to either question above, please explain the nature of the charge or crime, date of issuance or conviction and state in which issued or convicted.

Yes No

11b. Please explain

12. How did you hear about VEMA Corporation?

Online Flyer Referred by who: Other:

12b. Specify

13. Do you know someone who is currently working at VEMA Corporation? If yes, who?

Yes No

13b. Name of person you know working at VEMA Corporation:

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EMPLOYMENT EXPERIENCE

1. Company Name

Job Title

Supervisor

Phone

Rate of Pay: Hourly/Annually

May we contact supervisor?

Yes No

Employment Dates: From - To

2. Company Name

Address

Job Title

Supervisor

Phone

Rate of Pay: Hourly/Annually

May we contact supervisor?

Yes No

Employment Dates: From - To

3 List References that are not family related. Please list Name, Address, Relationship, & Phone Number.

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Please read the following and sign your application: This application is meant as a means by which VEMA Corporation can review your qualifications and decide if your qualifications are appropriate for a position that might be offered. This application does not serve as a means by which you will or will not receive a position. If a position is offered and you accept, then you must abide by the rules, policies and procedures set forth by VEMA Corporation. VEMA Corporation is an at-will employer. No person, entity, or any form of communication, written or oral, can make a contract with you and VEMA Corporation that can be construed as an employment contract – implied or not. Your employment at VEMA Corporation can be terminated either by you or by VEMA Corporation, through its agents, at any time. VEMA Corporation reserves the right to update and revise its policies, procedures and rules: you agree to be bound to these changes now and in the future. From time to time, VEMA Corporation may alter how it organized itself, its rules, procedures, processes, regulations, benefits or other areas of interest. These alternations may affect you. VEMA Corporation may perform a background check on you; you agree to release all parties, VEMA Corporation and those contracted from liability. VEMA Corporation may perform a background check in addition to the fingerprinting process. VEMA Corporation will contact your previous employers and references. Additionally, VEMA Corporation may contact other persons or entities not listed in this application. You hereby authorize VEMA Corporation to investigate all material. The information provided here will be taken as true. If any provided material is determined to be fabricated, which would be determined at the sole discretion of VEMA Corporation and you may or may not be able to review or defend such a decision, then that discovery could result in denial of a position or a revocation of employment at any time without notice. Upon start of employment, all employees are placed on a six-month probationary period. Upon successful completion of probation, you will be a full time/part-time status employee. During this probation period your supervisor and you will meet to ensure your experience and education meet the requirements for the position you were hired to fill. By signing this application, I agree to be bound by the above terms and conditions. I further acknowledge that additional rules, procedures and regulations may be presented. I agree to be bound by those additional rules, procedures and regulations. In addition, by signing this application, does not constitute employment.

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