Name *
Name
Address *
Address
Phone *
Phone
Referral Source
Are you presently legally authorized to work in the United States of America on a full-time basis? *
Have you ever been employed by Valley House Rehabilitation Center previously? *
Are you currently employed? *
May we contact your present employer? *
Please check the box that indicates the work hours you would prefer. *
Please check the box that indicates the shift you would prefer to work. *
Do you have any physical limitations that would prevent you from performing the job you are applying for? *
Have you ever filed or have been a party to a workers’ compensation claim? *
GOVERNMENT PROGRAM SANCTIONING: Are you or have you ever been suspended, excluded or debarred otherwise sanctioned from doing business with a government program, or have you ever been convicted of a health related offense? *
*(A “yes” answer to either of the two questions will not necessarily disqualify you for employment. A conviction or pending arrest will be considered only as it is relevant and / or related to that job in question and will therefore require further investigation and more in depth discussion before an employment decision can be reached)
Please Read Carefully and Submit: This application shall only remain active for 60 days. After 60 days, if you are still interested in employment at Valley House Care Center, you must fill out a new application. I hereby certify that all statements made in this application are true and correct to the best of my knowledge and belief. I understand and agree that any misrepresentation of mission of facts in my application may be justification for refusal to hire, or termination of employment. I further understand that an investigative report may be made as to my character and general reputation. I authorize all past employers, schools, persons and organizations having relevant information or knowledge to provide it to Valley House Care Center or its duty authorized representatives for its use in deciding whether or not to offer me employment and specifically waive any liability in responding to inquire in connection with my application. Upon written request by me, within a reasonable period of time, Valley House Care Center will make available to me the nature and scope of all reports of every type obtained. I understand that nothing contained in this employment application or in the granting of an interview is intending to create an employment contract between Valley House Care Center, its subsidiaries and affiliates, and me for either employment or for the providing of any benefit. If I am offered and accept employment, I understand that the employment is for no definite period of time and may, regardless of the date and payment of my wages and/or salary be terminated by either party for any legal reason. By submitting this form, I certify that I understand all the questions and statements in this application. *

The facility reserves the right to conduct a background check on any and / or all employment applications as well as current employees.  Background checks are routinely done by the State of California on all Certified Nursing Assistants.