.EVENT: Stevenson University

First name*

Last name*

Email address*

Location *

Phone number*

Resume*

What is your middle name?*

How did you hear about Visiting Angels?*

SECTION 2 - BASIC EMPLOYMENT QUALIFICATIONS
Are you legally authorized to work in the United States?*

This position requires completion of job-related background screening, registry checks, and/or credential verification as permitted or required by applicable law. If selected to proceed in the hiring process, are you willing to complete the required screening process?*

Are you at least 18 years of age?*

SECTION 3 - TRANSPORTATION AND DRIVING
Are you able to reliably report to client locations that you agree to accept within your stated availability and geographic preferences?*

Some caregiver assignments may include driving or transporting a client. Are you willing to be considered for assignments that require driving?

Do you currently hold a valid driver's license?

If assigned to transport a client using your own vehicle, are you willing and able to satisfy Visiting Angels' applicable vehicle and insurance requirements?

SECTION 4 - CAREGIVING EXPERIENCE
How much caregiving experience do you have?*

What types of caregiving experience do you have? Select all that apply.*

SECTION 5 - LICENSES, CERTIFICATIONS, AND CREDENTIALS
Which current or pending healthcare licenses, certifications, registrations, or other credentials do you hold? Select all that apply.*

If you selected a license, certification, registration, or other healthcare credential above, please identify the credential and issuing state or jurisdiction. You may also provide the credential number if readily available.

SECTION 6 - AVAILABILITY
Please identify the days and times you are generally available to accept client assignments. Do not provide the reason for any period when you are unavailable. Visiting Angels will address requests for reasonable accommodation as required by applicable law.

How many days per week are you generally available to work on a consistent basis?*

Which days are you generally available to work? Select all that apply.*

What is your general shift availability? Select all that apply.*

Please describe your other or variable availability.

SECTION 7 - EMPLOYMENT HISTORY
Most Recent Work Experience: Please provide the following information in the box below.

Company Name*

Employer City and State*

Employer Phone Number*

Start Date of Employment*

End Date of Employment*

Position Held*

Supervisors Name*

Reason for leaving, if you wish to provide it. Please do not include medical information, family medical history, or other sensitive personal information.

Prior Work Experience: Please provide the following information in the box below.

Company Name*

Employer City and State*

Employer Phone Number*

Start Date of Employment*

End Date of Employment*

Position Held*

Supervisor's Name*

Reason for leaving, if you wish to provide it. Please do not include medical information, family medical history, or other sensitive personal information.

Prior Work Experience: Please provide the following information in the box below.

Company Name*

Employer City and State*

Employer Phone Number*

Start Date of Employment*

End Date of Employment*

Position Held*

Supervisor's Name*

Reason for leaving, if you wish to provide it. Please do not include medical information, family medical history, or other sensitive personal information.

SECTION 8 - ADDITIONAL CAREGIVING EXPERIENCE
Please share any additional information about your caregiving experience that would help us understand your job-related qualifications and skills. You may describe the caregiving tasks you performed, the approximate length of your experience, the setting in which care was provided, and any specialized caregiving skills or training.

If your experience includes unpaid caregiving for a family member or another individual, you may describe the caregiving tasks you performed, the approximate length of your experience, and the care setting.

Do not identify the person you assisted or provide the person's relationship to you, diagnosis, medical history, genetic information, disability, or other health information.

SECTION 9 - TRAVEL AND GEOGRAPHIC AVAILABILITY
Caregivers may be offered client assignments located up to approximately 35 minutes from their home, subject to their stated availability and geographic preferences. Are you generally willing to commute up to 35 minutes from your home to an accepted client assignment?*

If you answered No to the above question, what is the maximum one-way commute time you are generally willing to accept?

In which service areas are you willing to accept client assignments? Select all that apply.*

SECTION 10 - MARYLAND POLYGRAPH NOTICE
UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A POLYGRAPH EXAMINATION OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.

By typing my full legal name below, I intend my typed name to serve as my electronic signature acknowledging the Maryland polygraph notice above.

I acknowledge that I have read the Maryland polygraph notice above.
Applicant Electronic Signature:*

SECTION 11 - AT-WILL EMPLOYMENT NOTICE
Employment with Visiting Angels is at will unless otherwise provided by a written agreement executed by an authorized representative of Visiting Angels. This means that either the employee or Visiting Angels may end the employment relationship at any time, with or without notice and with or without cause, subject to applicable law. Nothing in this application creates a contract or guarantee of employment for any particular period.

SECTION 12 - APPLICANT CERTIFICATION
I certify that the information I have provided in this application is true and complete to the best of my knowledge. I understand that a material false statement, material misrepresentation, or material omission concerning job-related information may result in withdrawal of consideration

SECTION 13 - VERIFICATION AUTHORIZATION
I authorize Visiting Angels to verify job-related information I have provided in this application, including employment dates, positions held, education, licenses, certifications, registrations, and other job-related credentials, to the extent permitted by law.

This authorization does not authorize Visiting Angels to obtain my prior wage or compensation history, medical information, family medical history, genetic information, or a consumer report. Any consumer report or other background screening requiring a separate disclosure or authorization will be handled through a separate process as required by applicable law.

SECTION 14 - EQUAL EMPLOYMENT OPPORTUNITY
Visiting Angels is an equal opportunity employer. Employment decisions are made without unlawful discrimination or retaliation on any basis protected by applicable federal, Maryland, District of Columbia, or local law.

SECTION 15 - ACCOMMODATION NOTICE
Visiting Angels provides reasonable accommodations to qualified applicants as required by applicable law. If you need a reasonable accommodation to participate in the application or hiring process, please contact Human Resources.

SECTION 16 - FINAL ELECTRONIC CERTIFICATION
By submitting this application, I certify that I have read and understand the applicant certifications and notices above and that the information I have provided is accurate to the best of my knowledge.

Applicant Electronic Signature and Date:*

Human Check*