NAME:

PERMANENT ADDRESS:

Previous Addresses:

Please include previous temporary and permanent addresses covering the last seven years.

If yes, please provide us with the specific nature and details of the crime(s), date(s), court location, sentencing information and disposition of sentence. (Please note: a conviction record will not necessarily be a bar to employment.)

PERMANENT ADDRESS:

Select highest grade completed:

EMPLOYMENT RECORD

(List most recent first)

Explain and give details of any period of unemployment longer than 30 days

REFERENCES:

(Other than relatives or former employers, List 3)

After a conditional offer of employment, I understand that a physical examination and a post-offer drug screen satisfactory to VestraCare must be passed. I authorize investigation of any information provided on this application. I also authorize investigation of my employment record and references. I understand that a background check will be performed on every candidate under consideration and that I authorize, with a signature, such as a check, releasing VestraCare from all legal liability. I understand that any misrepresentation, falsification, or omission is cause for voiding this application or termination of employment if hired. I understand that any misrepresentation, falsification, or omission is cause for voiding this application or termination of employment if hired. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages or salary, be terminated at any time without prior notice.

ADDENDUM TO EMPLOYMENT APPLICATION

(Please note: A conviction record will not necessarily be a bar to employment. Factors such as the seriousness and nature of the violation and rehabilitation will be taken into account.)