* = Required Information

APPLICANT INFORMATION

Full Time Part Time On-Call
Yes No
Yes No

If you are offered a position, you will be required to provide documentation to verify eligibility.

Yes No
Yes No

A conviction will not necessarily automatically disqualify you for employment. Rather, such factors as age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered.

EDUCATION AND TRAINING

Yes No
Yes No
Yes No

Yes No

Yes No



PREVIOUS EMPLOYMENT

(Must show a minimum of 5 years employment history.)

Please list most recent employment first, including military experience.

Dates of Employment (mo/yr)
FT PT
Yes No

Dates of Employment (mo/yr)
FT PT
Yes No

Dates of Employment (mo/yr)
FT PT
Yes No

Dates of Employment (mo/yr)
FT PT
Yes No

Yes No
Yes No

REFERENCES



APPLICANT CERTIFICATION AND AGREEMENT

I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Victory Staffing & Home Care, Inc. to verify their accuracy and to obtain reference information on my work performance. I hereby release Victory Staffing & Home Care, Inc. from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information.

I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal.

I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of Victory Staffing & Home Care, Inc. However, I further understand that neither the policies, rules, regulations of employment or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either I or the Employer may terminate my employment at any time with or without notice or cause.

Security code