VA Job Applicant Form

VA Job Applicant Form

Recitals

WHEREAS, Employer: (the "Employer") operates programs and facilities and seeks qualified personnel to perform specified duties; and

WHEREAS, Applicant Name: (the "Applicant") submits this form to be considered for employment and agrees to the terms and authorizations set forth herein; and

NOW, THEREFORE, the Applicant provides the information below and agrees that, if extended an offer of employment, the Applicant will be bound by the employment provisions, confidentiality, and other terms set forth in this application and any subsequent offer or agreement.

Applicant Information

Date of Birth:    Social Security Number (last 4 digits only):

Position & Availability

Desired Start Date:    Employment Type Desired: Full-time Part-time Temporary

Education

Employment History (most recent first)

References

Scope of Work (If offered hire, primary duties)

Payment Terms

Proposed Annual Salary: $    Pay Schedule:

All compensation is subject to applicable deductions and withholdings required by law. Employer reserves the right to adjust compensation consistent with written offer. Late payment of wages by Employer (where applicable) shall be handled in accordance with statutory requirements and any applicable policy; Applicant acknowledges that remedies for withheld or disputed pay are governed by applicable law.

Term and Termination

Start Date:    Anticipated End Date (if temporary):

Either party may terminate employment in accordance with applicable law and any written offer or employment agreement. Unless otherwise specified in a separate written agreement, termination by either party requires notice of: days, except that Employer may terminate immediately for cause.

Confidentiality

Applicant acknowledges that, in the course of employment, Applicant may receive access to confidential or protected information. Applicant agrees that all such information is the property of Employer and subject to nondisclosure obligations. Confidential information includes, but is not limited to, patient and personnel records, operational protocols, and proprietary procedures. Applicant further agrees to execute any additional confidentiality or non-disclosure agreement required by Employer as a condition of hire.

Background Checks & Certifications

Applicant hereby authorizes Employer to obtain background checks, criminal history, employment verification, education verification, and any required credential checks. Applicant certifies that the information provided in this form is true and complete to the best of Applicant's knowledge. False statements, omissions, or failure to disclose requested information may be grounds for rejection of the application or termination of employment.

Governing Law; Entire Agreement

This form and any subsequent offer of employment shall be governed by the laws of the state or jurisdiction in which the employing facility is located, without regard to conflict of law principles. This form, together with any written offer or employment agreement executed by the parties, constitutes the entire agreement between Applicant and Employer regarding the subject matter herein and supersedes all prior discussions and understandings.

Applicant Certifications

By signing below, Applicant certifies that the statements made in this application are true and complete, that Applicant understands that any employment is contingent upon satisfactory background checks and compliance with Employer policies, and that Applicant will promptly notify Employer of any change in the information provided.

Additional Information

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