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Name:

Phone:

Date of Birth

City

Street Address

State

Zip Code

Email:

Position Applying for

LPN

CMA

CNA

desired shifts, full or part time

Desired Salary for this job (not including stipends)

Are you eligible to work in the US?

Are You 16yrs of age or older?

Have you ever been convicted, pled guilty or no contest to a crime? This includes misdemeanors (except parking violations), gross misdemeanors and felonies. A conviction, guilty plea or no contest will not necessarily disqualify you for employment consideration.

Yes

If yes, gives dates and explanation (where, when, etc)

Have you ever been disciplined by professional or state ethics or licensing board?

Yes

If yes please explain

Education Information

High School and address

Did You Graduate?

Yes

College or University and address

Major

Did You Graduate?

Yes

Degree

1. Employer (Most Recent)

Address- City/State/zip

Supervisor Name/Phone No.

Start Date

End Date

Position

Ending Salary (Not required for Colorado)

Reason For Leaving

2. Employer

Adress- City/State/Zip

Supervisor Name/Phone No.

Start Date

End Date

Position

Ending Salary (not required for Colorado)

Reason For Leaving

3. Employer

Address- City/ State/ Zip

Supervisor Name/Phone No

Start Date

End Date

Position

Ending Salary (not required for Colorado)

Reason For Leaving

Our company is committed to respectful and equal treatment for all employees. This commitment includes non-discrimination towards applicants and employees on the grounds of race, color, creed, religion, age, sex, disability, national origin, ancestry, sexual orientation, marital status, or with regard to public assistance, or union or non-union status. This prevails throughout the employment relationship, including, but not limited to recruitment, selection, training, transfer, compensation, promotion, demotion, layoff and termination.

Most Recent Supervisor Name

Company

Telephone Number

May We Contact This Person For A Reference

Yes

Reference One (Name)

Company

Telephone Number

How Do You Know This Person?

Reference Two (Name)

Company

Telephone Number

How Do You Know This Person?

Reference Three (Name)

Company

Telephone Number

How Do You Know This Person?

Applicant Release, Please read and sign below: I authorize the investigation of my background including all information contained in this application and information provided in the interview. I understand that misrepresentation or omission of information in connection with my application and interview will be sufficient cause, in and of itself, for rejection or dismissal whenever discovered. I understand and agree that any offer of employment is contingent upon satisfactory completion of Vision Staffing LLC pre-employment investigation which includes but is not limited to health assessment, criminal history check, educational and work verification, reference checks, consumer report and any investigation required by local, state, or federal laws. I understand that if I am hired by Vision Staffing LLC, my employment will be for an indefinite period of time and will be “at will” which means that either Vision Staffing LLC or I may terminate the employment relationship at anytime and for any reason or no reason. I further understand that, if hired, my at-will employment status my only be changed in written contract signed by the management of Vision Staffing LLC, and that no representative of Vision Staffing LLC,has the authority to make oral promise to me concerning my employment. Finally, I also understand that Vision Staffing LLC, may adopt, from time to time, policies or handbooks dealing with benefits and other terms or conditions of employment. These policies or handbooks do not constitute a contract of employment between Vision Staffing and me. Vision Staffing LLC reserves the right to change or discontinue these policies and/or handbooks at any time with or without notice to me. Vision Staffing LLC strives to provide a safe, healthy and productive work environment and supports a smoke free, alcohol-free work environment.

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Please provide name and date in the box above the submit button prior to submission of application. By adding, this is a statement of the application being filled out truthfully to the best of your knowledge. We look forward to speaking with you.

ALL STAFF UNDERGO BACKGROUND CHECK, ABUSE AND NEGLECT, OIG, SAM, SEX OFFENDER REGISTRY CHECK, DRUG TEST, LICENSE VERIFICATION, TB, CPR. PACKETS ARE SENT UPON FIRST SHIFT TO EACH FACILITY STAFF IS PLACED AT

Contact Us

Call us: +1 402-204-8156

email: ceo@visionstaffingllc.com

3157 Farnam Street, Ste 7104 #7231,

Omaha, Nebraska, 68131 United States

Business Hours

nOpen 7 days a week 24 hours a day for scheduling

Monday - Friday 8a-5p for applications

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