APPLICATION FOR EMPLOYMENT AN EQUAL OPPORTUNITY EMPLOYER

Transcription

1 APPLICATION FOR EMPLOYMENT AN EQUAL OPPORTUNITY EMPLOYER 2120 Belcourt Avenue Nashville, Tennessee Phone: (615) Fax: (615) Last Name First Middle Initial Mailing Home Phone: Message Phone: City State Zip Position/type of position desired: Are you authorized to work in the United States? Yes No Employment Interests: Regular Temporary Full-time Full-time Part-time Part-time Weekends Only Summer Are you available if required? Holidays: Yes No Overtime: Yes No Shift Preference: 1st shift 2nd shift 3rd shift Any shift Weekends: Yes No Are you at least 18 years of age? Yes No Date available to begin work: Minimum salary desired: Previous Vanderbilt Employment Yes No Dates: Departments: Relatives employed at Vanderbilt Names: Departments: Office machines, computers and other equipment you can operate: Average typing WPM Have you ever pleaded guilty or been convicted of a crime other than minor traffic violations? Yes No If yes, please explain. (Convictions are NOT necessarily a bar to employment - please fill out a conviction record form available at reception desk). Have you ever been discharged or resigned in lieu of being discharged by an employer? Yes No If yes, please explain. Drivers license no. if required: State: Complete this section if you served in the U.S. Armed Forces. Branch of Service: Describe duties, relevant training, and rank at discharge: Other certification/licensure, type and number: Expiration Period of Active Duty: Circle highest grade completed: Elementary High School College Name And Location Of School Dates Attended Major Course of Study Degree Received College College High Elementary Other

2 List most recent employment first. Complete all questions, in full. Ask for addendum if additional employment space is needed. We will contact the employers listed above for employment references unless you indicate otherwise: Do not contact: Additional Information or Comments: Reason: In compliance with federal law, including the provisions of Title IX of the Educational Amendments of 1972, Sections 503 and 504 of the Rehabilitation Act of1973, and the Americans with Disabilities of 1990, Vanderbilt University does not discriminate on the basis of race, sex, religion, color, national or ethnic origin, age, disability, or military service in its administration of educational policies, and loan programs; athletic or other University-administered programs; or employment. Inquiries or complaints should be directed to the Opportunity Development Officer, Baker Building, P.O. Box 1809, Station B, Nashville, TN (615) , (V/TDD); fax (615) The applicant agrees, if employed by Vanderbilt, to be bound by all employee regulations and the provisions of the Staff Handbook concerning Inventions, Discoveries, and Patents. Vanderbilt reserves the right to revoke any offers of employment, or declare void, or rescind any employment should misrepresentation appear on this form or be made by the applicant in interviews. Your signature will be considered a release to verify any information on this form for accuracy. Vanderbilt University also reserves the right to conduct medical testing of individuals to whom employment offers have been made, and to make any employment offers contingent upon satisfactory results on such tests. Signature Interviewed by: Personnel Use Only: Date Interview

3 Addendum for Additional Employment (optional) We will contact the employers listed above for employment references unless you indicate otherwise: Do not contact: Reason: Additional Information or Comments:

4 AUTHORIZATION FOR RELEASE OF RECORDS Name: : (please print) Date of Birth: Maiden Name (if applicable): I do hereby consent to and authorize Vanderbilt Home Care Services and Vanderbilt University to complete a security check, including the release of any police records to any agent of Vanderbilt Home Care Services or Vanderbilt University for use in connection with my application for employment with said company. I hereby release Vanderbilt University and Vanderbilt Home Care Services, Inc., their officers, agents and employees from any and all claims, actions, or suits, for damages or injuries of whatever nature that may result from the release of any records or security check pursuant to this authorization. Signature: Witness: FOR OFFICE USE ONLY: Background America: OIG: Abuse Registry: No record found No record found No record found Signature:

5 Name: CONFIDENTIAL REFERENCE REQUEST (please print) The above individual has applied for employment with Vanderbilt Home Care Service. Please complete and return the form below so that we can give the application proper consideration. We appreciate your prompt attention to this reference request. I hereby release from all liability the company or person completing this form and authorize them to release all information regarding my employment with them. Applicant s Signature: Dates Employed: From: To: Position Held: EMPLOYMENT REFERENCE: Is the above employment information correct? Yes No If no, please explain: Please rate the applicant by entering your response using the following guidelines: Excellent Good Adequate Unsatisfactory Technical Ability Loyalty Attendance Record Quality of Work Initiative Gets Along With Others Contact Person: Unable To Evaluate Is employee eligible for rehire? Yes No

6 Name: CONFIDENTIAL REFERENCE REQUEST (please print) The above individual has applied for employment with Vanderbilt Home Care Service. Please complete and return the form below so that we can give the application proper consideration. We appreciate your prompt attention to this reference request. I hereby release from all liability the company or person completing this form and authorize them to release all information regarding my employment with them. Applicant s Signature: Dates Employed: From: To: Position Held: EMPLOYMENT REFERENCE: Is the above employment information correct? Yes No If no, please explain: Please rate the applicant by entering your response using the following guidelines: Excellent Good Adequate Unsatisfactory Technical Ability Loyalty Attendance Record Quality of Work Initiative Gets Along With Others Contact Person: Unable To Evaluate Is employee eligible for rehire? Yes No