Job Application

Comments

This field is for validation purposes and should be left unchanged.

The BVNA is an equal opportunity employer and will not discriminate, or tolerate discrimination, against any applicant or employee in any manner prohibited by law.

Applicants may request any accommodation needed to enable them to complete the application by contacting the Human Resources Department Representative.

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Best Phone(Required)

Alternate Phone

Email(Required)

Were you ever employed by the Brockton Visiting Nurse Association?(Required)

Yes

Job Title

Dates

Supervisor

Reason for leaving

How were you referred to the agency?(Required)

Employee Referral

Indeed/Social Media

Career Fair

Print Advertising

BVNA Website

Other (please specify)

Name of Employee

If applying for a clinical position, do you have a Massachusetts driver's license and a reliable automobile?

Yes

Position applying for:(Required)

Date available for work:(Required)

Are you interested in working:(Required)

Full-time

Part-time

Per Diem

Weekends and holidays

On-call

Have you reviewed the essential functions of the job for which you are applying?(Required)

Yes

If no, please explain

Are you able to meet the requirements of this position?(Required)

Yes

Job skills:

Electronic Medical Record (EMR) skills- please specify EMR (s)

PC skills

Medical Terminology

Languages- please specify language (s)

Specify languages

Other Software Applications:

Nursing Specialization:

Phlebotomy

Intravenous Care

Wound Care

Negative Pressure Wound

Therapy / Vacuum- Assisted Wound Closure (VAC)

Professional license/registration

Type:

State:

Number:

Expiration date:

If you have a professional license, has the issuing agency ever disciplined you or the scope of your practice in Massachusetts or any other state in which you have been licensed?

Yes

If yes, please explain

Have you ever surrendered your professional license?

Yes

If yes, please explain

Has your professional license ever been suspended?

Yes

If yes, please explain

Are you currently on the Office of the Inspector General Exclusion List or otherwise ineligible to participate in any state/federal health care programs?

Yes

If yes, please explain

Education

What is your education level?(Required)

High School Diploma

High School Equivalency

College

Nursing School

Graduate School

Other

Name and location of high school

Name and location of college

Include degree obtained

Name and location of nursing school

Include degree obtained

Name and location of graduate school

Include degree obtained

Name and location of other institution

Include degree obtained

Work Experience

Start with your most recent work experience. Describe all traditional, military, and volunteer work experience. If you were self-employed, please give the business/firm name.

Employer Name, Address and Phone Number

Job Title/ Hours Worked

Dates employed

Enter from/to dates of employment

Superviser Name/Title

May we contact this employer for reference?

Yes

Employer Name, Address and Phone Number

Job Title / Hours Worked

Dates (from/to)

Superviser Name/Title

May we contact this employer for reference?

Yes

Employer Name, Address and Phone Number

Job Title / Hours Worked

Dates (to/from)

Supervisor Name/Title

May we contact this employer for reference?

Yes

Additional Employers

Additional Employers may be listed here.

Professional References

List managers or supervisors who can attest to your experience. Please include name, title, address and phone number.

Upload Resume(Required)

Max. file size: 256 MB.

Application Terms(Required)

I agree

By completing and submitting this application, I certify that the information provided by me is complete and true to the best of my knowledge. I understand that any misrepresentation or omission on this application may preclude an offer of employment, or may result in a withdrawal of an employment offer, or may result in my discharge from employment if I am already employed at the time the misrepresentation or omission is discovered. I authorize the Brockton Visiting Nurse Association (BVNA) to check references and verify the information I have provided on this application and/or resume. Applications become a part of the permanent record of the employee once hired.

Professional license/registration

Education

Work Experience

Contact Information

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