Careers Form

Reference Number

Position for which you are applying:

Last Name *

First Name *

Middle Initial *

Street Address *

City

State

Zip Code

Telephone

Email *

Type of work you prefer:

Full-time

Part-time

Limited Service (9 or 10 months/year)

Referred by

Agency

Print Ad

Newspaper/Magazine

Do you have the right to work in the U.S.?

Yes

No

Indicate visa type

Visa number

Expiration Date:

Have you applied previously to VHS?

Yes

No

Date:

Are you currently employed at VHS?

Yes

No

Most recent Supervisor & Dept. at VHS

Is any family member a VHS employee?

Yes

No

Name

Department

Relationship

Do you have a valid driver's license?

Yes

No

If you are under the age of 18, do you have working papers?

Yes

No

What is your desired salary?

High School

No. of Years Completed Diploma or Degree

Program or Major

Vocational-Technical School

No. of Years Completed Degree / Year Graduated

Program or Major

College

No. of Years Completed Degree / Year Graduated

Program or Major

Graduate/Professional School

No. of Years Completed Degree / Year Graduated

Program or Major

Other Specialized Training/Certification

No. of Years Completed Degree / Year Graduated

Program or Major

Most Recent Employer:

Starting Salary:

Ending Salary

Address

City & State

From

To

Reason for leaving

Supervisor’s Name/Title:

Telephone:

Duties Performed:

Most Recent Employer:

Starting Salary:

Ending Salary

Address

City & State

From

To

Reason for leaving

Supervisor’s Name/Title:

Telephone:

Duties Performed:

Most Recent Employer:

Starting Salary:

Ending Salary

Address

City & State

From

To

Reason for leaving

Supervisor’s Name/Title:

Telephone:

Duties Performed:

Veracity Health Systems LLC (VHS) values diversity and seeks talented staff from diverse backgrounds. Veracity Health Systems LLC does not discriminate on the basis of race, color, sex, sexual orientation, gender identity, religion, creed, national or ethnic origin, citizenship status, age, disability, veteran status or any other legally protected class status in the administration of VHS.

Please read carefully and sign:

I have carefully read the application statement and have provided accurate information to the best of my knowledge. The facts set forth in this application are true and complete. Permission is given to Veracity Health Systems LLC to verify all information I have provided in this application. I authorize all persons or entities I have referred to in this application to provide any relevant information to Veracity Health Systems or its agents for use in investigation and release them from any liability doing so.

I understand and agree that any omission or misrepresentation of facts in my application will be justification for refusal or termination of employment. I understand that this employment application and any other VHS documents or statements are not contracts of employment. I acknowledge that employment at VHS is at will, meaning I will be free to leave at anytime and my appointment may be terminated for any reason at any time. Employment is contingent upon satisfactory completion of employment and reference checks. A minimum of two reference checks are required for employment, one of which must be from the applicant’s current supervisor.

Date Signed

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