To enlarge or zoom pages for improved readabililty PC users press (ctrl) and (+) | MAC users press (Command) and (+)
Vets Caring for Vets &
Veterans at Your Service
In-Home Care Provider
Employment Application
General Information
  1. required required
  2. Present Address
  3. required required required requiredInvalid format.
  4. Permanent Address (if different from above)
  5. Invalid format.
  6. Invalid format.required Invalid format.required
  7. Are You?             
  8. My height is:            
  9. I can transfer a client weighing #lbs with or without accommodation:         
  10. How fit are you?         
  11. Do you hold a license or certification?                 
  12. Could you drive the client to and from places?     
  13. Do you possess a valid drivers license?        
  14. Are you willing to work overnight?     
  15. Are you willing to work a 24 hour shift?     
  16. Do you prefer to work?        
  17. Do you prefer to work certain days?                                        , any day is fine
  18. Desired Rate of Pay?  
  19. Please indicate the city, and/or county, and state where you are willing to work?
  25. Additional Information:
  26. Are there any duties you won't perform?
Employment Desired
  1. Position applying for:  Caregiver / Personal Attendant
Personal Information
  1. Have you ever applied to or worked for Vets Caring for Vets?      
  2. Do you have any friends or relatives working for Vets Caring for Vets?     
  3. If yes, state name(s) & relationship:
  4. If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?     
  5. Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?     

  6. (Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)
  7. Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? (Convictions for marijuana-related offenses that are more than two years old need not be listed)     

  8. (Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)
Education, Training and Experience
  1. High School
  2.    Did you Graduate?    
  3. College/Jr. College/University
  4.    Did you Graduate?    
  5. Vocational/Business
  6.    Did you Graduate?    
  7. Health Care Training
  8.    Did you Graduate?    
  9. Health Care Training
  10.    Did you Graduate?    
Employment History
  1. List below all present and the last 5 years past employment starting with the most recent employer. Account for all periods of unemployment. You must complete this section even if you also submit a resume.
  2. Date of Employment:     Weekly Pay:
  3. May we contact this employer for a reference?
  4. Date of Employment:     Weekly Pay:
  5. May we contact this employer for a reference?
  6. Date of Employment:     Weekly Pay:
  7. May we contact this employer for a reference?
  8. Date of Employment:     Weekly Pay:
  9. May we contact this employer for a reference?
  10. Date of Employment:     Weekly Pay:
  11. May we contact this employer for a reference?
  1. List below three persons not related to you who have knowledge of your work performance within the last three years.
Please Read Carefully and Check Off each Paragraph Below
  1. required I hereby certify that I have not knowingly withheld any information that might adversely affect chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
  2. required I hereby authorize Vets Caring for Vets to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
  3. required I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Company's designated representative.
  4. required Should a search of public records (including records documenting an arrest, indictment, conviction, civil judicial action, tax lien or outstanding judgment) be conducted by internal personnel employed by the Company, I am entitled to copies of any such public records obtained by the Company unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have checked the box below.
  5. required I waive receipt of a copy of any public record described in the paragraph above.

Please email any additional information to:
Please include your name and phone number with each email or document sent.