Employment Application Step 1 of 9 - Contact Information 11% Name(Required) First Last Address Street Address Address Line 2 City NebraskaAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Enter Email Confirm Email Phone(Required)Social Security Number Position(s) Applying For(Required)How were you referred to VITAL Services Inc.?(Required)EmployeeFriendOtherIf "Other", please enter the details here If VITAL Services Employee or Friend, who? Have you applied for employment with VITAL Services Inc. Before? If yes, when? Doing what?(Required) Are you employeed?(Required) Yes No If yes, may we contact your present employer? Yes No Are you under the age of 19?(Required) Yes No Do you have a valid driver's license?(Required) Yes No Have you had any moving violations in the last 5 years? Include speeding ticket(s). Yes No Are you prevented from lawfully becoming employed in the USA because of Visa or Immigration Status?(Required) Yes No Have you ever been convicted of a felony? (Conviction will not necessarily disqualify an applicant from employment)(Required) Yes No If yes, please explain. Are you interested in working:(Required)Full-TimePart-TimeTemporaryAre you currently on "lay-off" status and subject to recall?(Required) Yes No If hired, when would you be available to start?(Required) Month Day Year Which schedules would you prefer, if hired? Check all that apply:(Required) Weekdays Weekends Evenings Sleepovers Nights Overtime Shift Other Select All Highest grade completed in school:(Required) 8 or less 9-12 GED Name of High School: City/State(Required) Year of college, technical or business school:(Required) 1 2 3 4 Diploma?(Required) Yes No Current/last school attended? City/State(Required) Major or area of study?(Required) List any other skills, licenses or certificates you have that are related to this job or VITAL.List any volunteer activities you've done that relate to this job or VITAL.List professional, trade, business or civic activities and offices held that you feel would be of value to this job or VITAL. You may exclude membership which would reveal gender, race, religion, national origin, age ancestry, or any other protected status. Employeer #1Name of Employer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer's PhoneStart Date Month Day Year End Date Month Day Year Last Pay RateName of Supervisor Job Title Reason for Leaving Are you eligible for rehire? Yes No Job Duties were:Employeer #2Name of Employer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer's PhoneStart Date Month Day Year End Date Month Day Year Last Pay RateName of Supervisor Job Title Reason for Leaving Are you eligible for rehire? Yes No Job duties were: Reference #1Name Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State PhoneReference #2Name Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State PhoneReference #3Name Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Phone Upload Cover LetterAccepted file types: pdf, Max. file size: 300 MB.Upload ResumeAccepted file types: pdf, Max. file size: 300 MB. Read thoroughly before signing – ask for clarification if there is something you don’t understand.I certify that the answers given in this application are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this “Application for Employment” as may be necessary for arriving at an employment decision. I authorize any agent of VITAL Services Inc. to contact previous employers and my personal references for the purpose of verifying any information given in this application and for references regarding my character and work history. I further authorize any agent of VITAL Services Inc. to conduct a background check through one or more of the following: I also authorize any agent of VITAL Services Inc. to access and print my Motor Vehicle Record (MVR) from the internet – upon employment, and also anytime during employment with VITAL Services Inc., in order to satisfy the insurance carrier of my satisfactory driving records. This application for employment shall be considered active for a period of time not to exceed 60 days. (Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.) In the event of employment by VITAL Services Inc., I understand that: False or misleading information given in my application or interview(s) may result in discharge. I will be required to authorize downloading a current Motor Vehicle Record at my expense. I will be required to abide by all Policies and Procedures of VITAL Services Inc. I will be required to satisfactorily complete all required training within time allowed. I will be expected to stay informed of all current and revised rules, Policies and Procedures. I will be expected to get a drug test at NE Occupational Health before orientation or training will begin. Signature(Required) Date MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
