LN Application

Dear Applicant,

Thank you for your interest in Vital Care Services. In order to apply for the LN position, please fill out the online application below, as well as, be prepared provide updated originals (copies to be made at the office) of the following documents:

Please send copies of:

Resume
Driver’s License
Social Security Card
Current physical exam with immunization such as TB Test, Rubella, Rubeola, Varicella
CPR and other nursing training certificates (BLS OR ACLS)
State of Georgia Nurse Aide Certification, RN/LPN Georgia License
Car Insurance

Upon review of your application and the required documents, we will contact you for an initial interview and orientation. Please note, all documents must be completed before an orientation can be scheduled.

Best of luck!

Director of Clinical Services

Date

First Name

Last Name

Address

City

State/Province/Region

Date of Birth

Social Security Number

Contact Phone Home

Contact Phone Cell

Emergency Contact

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Address

Street Address

City

State / Province / Region

ZIP / Postal Code

Country

Emergency Contact Phone

Position

Position Desired

Salary Desired

Applying For:

Full Time Position Part Time Position

Indicate days and hours available to work

When are you available to start?

How did you hear about our Agency?

Employment History

Starting with the most recent, list your last two employers.

Employer#1 Name

Employer#1 From Date

Employer#1 To Date

Employer#1 Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Employer#1 Phone

Employer#1 Duties and Responsibilities

Employer#1 Full Time Ending Rate/Hour

Employer#1 Part Time Ending Rate/Hour

Employer #1 May We Contact your Supervisor?

Yes No

Employer #1 Supervisor Name

Employer #1 Supervisor Phone

Employer #1 Reason(s) for leaving

Employer#2 Name

Employer#2 From Date

Employer#2 To Date

Employer#2 Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Employer#2 Phone

Employer#2 Job Title

Employer#2 Duties and Responsibilities

Employer#2 Full Time Ending Rate/Hour

Employer#2 Part Time Ending Rate/Hour

Employer #2 May We Contact your Supervisor?

Yes No

Employer #2 Supervisor Name

Employer #2 Supervisor Phone

Employer #2 Reason(s) for leaving

General Employment Questions

Are you legal for employment in the United States?

Yes No

Have you ever been convicted of a crime at any time, other than a minor traffic violation? A conviction (misdemeanor or felony) includes a plea of "guilty" or "no contest." ( A "yes" answer will be considered for job related purposes only and will not automatically disqualify you from employment).

Yes No

If "yes," please explain:

Do you have any relatives working for Greenline Health Services?

Do you have previous employment existing under a different name?

If "yes," provide name

Educational History

High School Name

High School Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

High School: Select the number of years completed

One Year Two Years Three Years Four Years

College / University Name

College / University Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

College / University: Area of Study or Degree

College / University: Select the number of years completed

Other Educational Institute Name

Other Educational Institute Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Other Educational Institute Area of Study or Degree

Other Educational Institute: Select the number of years completed

Professional Licenses, Registrations, and/or Certifications

NOTE: FOR ANY POSITION REQUIRING REGISTRATION, LICENSE, OR CERTIFICATION, ORIGINAL DOCUMENT MUST BE PROVIDED

Are you currently

Registered Licensed Certified

Eligible for

Registered Licensed

Will take Boards (list date)

#1 Type

#1 State Issued

#1 Date Expires

#1 Number

#2 Type

#2 State Issued

#2 Date Expires

#2 Number

Vital Care Services, Inc is an in-home service provider that assists individuals and families.

Main Office

Office: 678.885.9765
Fax: 678.885.9764

148 Georgia Avenue, East Suite B
Fayetteville, GA 30214

Training Office

Office: 478.845.7650
Fax: 478.308.7935

3780 Northside Dr. Suite 140 | #440
Macon, Ga 31210

Emergency Contact

Position

Employment History

General Employment Questions

Educational History

Professional Licenses, Registrations, and/or Certifications

Main Office

Training Office

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