application form – Vitality Caregivers

Vitality Caregivers, LLC is an equal opportunity employer dedicated to a policy of non-discrimination in employment on any basis including race, color, religious creed, age, sex, marital status, veteran status, sexual orientation, national origin, ancestry, present or past history of mental disorder, mental retardation, learning disability, physical disability, or any other legally protected class.

Applicant Information

Last Name *

First Name *

M.I.

Date *

Street Address *

Apt / Unit #

City *

State *

ZIP Code *

Phone *

Email Address *

Date Available *

Social Security No.

Date of Birth

Position Applied For *

Desired Salary ($/hr)

Are you a citizen of the United States? *

Yes No

Authorized to work in the U.S.?

Yes No

Have you ever worked for this company? *

Yes No

If yes, when?

Have you ever been convicted of a felony? *

Yes No

If yes, please explain

Education

High School

Name & Address of School

Last Year Completed

Graduated?

Yes No

Subjects / Diploma

College / Technical School

Name & Address of School

Last Year Completed

Graduated?

Yes No

Subjects / Degrees

State Certified CNA?

Yes (copy required if hired) No

State Certified HHA?

Yes (copy required if hired) No

Licensed State(s)

Professional References

Please list three professional references.

Reference 1

Full Name

Relationship

Company

Phone

Address

Reference 2

Full Name

Relationship

Company

Phone

Address

Reference 3

Full Name

Relationship

Company

Phone

Address

Previous Employment

Employer 1

Company

Phone

Address

Supervisor

Job Title

Starting Salary $

Ending Salary $

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor?

Yes No

Employer 2

Company

Phone

Address

Supervisor

Job Title

Starting Salary $

Ending Salary $

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor?

Yes No

Disclaimer & Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Full Name (acts as Signature) *

Date *

By submitting you confirm all information is accurate. Vitality Caregivers, LLC will review your application and contact you if your qualifications match our current openings. Phone: (203) 919-0410

✅ Application submitted successfully! Thank you for applying to Vitality Caregivers, LLC. We will review your application and reach out to you soon.

❌ Something went wrong. Please try again or call us at (203) 919-0410 or email Admin@vitalitycaregivers.com

Employment Application