REFERAL INFORMATION

EMERGENCY CONTACT INFORMATION - Please Print Clearly

Alliance Homecare V.N.A an equal opportunity employer. All applicants and employees are considered for employment, advancement, and development based upon their skills, performance and potential. No current or prospective employee will be discriminated against because of race, creed, color, gender, age, national origin, handicap or military status. 

EMPLOYMENT HISTORY - Please begin with your most recent or current place of employment. 

LICENSES AND CERTIFICATIONS 

CRIMINAL HISTORY

if yes, please list conviction(s), date(s) and location(s). The presence of a criminal record is not an automatic rejection of your application. Certain types of convictions will eliminate you from servicing vulnerable elders in their homes. I attest that the above referenced information is true and accurate to the best of my knowledge. I further give the agency permission to call any of my cited previous employers or reference candidate for information regarding my character, employment history or work ethics. 

CHAPTER 6, § 172 C CORI REQUEST FORM 

Alliance Homecare V.N.A has been certified by the criminal History Systems Board to all the available criminal offender record information on the following individual from the Criminal History Systems Board pursuant to Chapter 6, § 172 C that mandates agencies which employ or accept as a volunteer or refer for employment any individual who will provide care , treatment, education, training, transportation, delivery of meals, instruction, counseling, supervision, recreation, or other services in a home or in a community based setting for any elderly person or disabled person or who will have and direct or indirect contact with such elderly or disabled persons or access to such person's files shall obtain all available CORI from the Criminal History Systems Board prior to employing such individual, accepting such individual as a volunteer or referring such individual for employment.