List any other names you have worked under.

Vibra Healthcare requires some positions to have a valid driver's license; therefore, if the position you are applying for requires a valid driver's license, a motor vehicle report will be completed.

PLEASE DO NOT ENTER DASHES, HYPHENS OR SPACES.

Were you previously employed by Vibra Healthcare?

List names and departments of relatives employed by Vibra Healthcare, or is subsidiaries.

If NO, employment is subject to verification that you are of minimum age.

Have you ever been convicted, plead Guilty or No Contest, or forfeited bond or bail for any crime whether classified as a felony, misdemeanor, or any other type of violation or offense? (You do not need to include any minor traffic violations or offenses.) Vibra conducts criminal background checks on all applicants as a condition of employment. (A criminal record is not an automatic bar to employment. Factors such as the nature and gravity of the crime, length of the time since the conviction and/or completion of any sentence, and the nature of the job for which you have applied will be considered.)

Can you perform the functions of the job to which you are applying to with or without reasonable accommodation?

Professional Affiliations

Please list any job-related professional, trade, business or civic activities, organizations, fellowships and associations in which you participated, or of which you are a member. (You may omit those which indicate race, color, religion, political affiliations, national origin, ancestry, sex or age.)

Have you received any specialized training which would qualify you for the position for which you are applying that you have not already listed on this application? If so, state what training or experience you have had.

I authorize the investigation of all matters which the Company deems relevant to my qualifications for employment, including all information given in this application and in any attachments, supporting documents or interviews. I authorize you to request and receive such information, and I agree to sign an Authorization and Consent form allowing an outside agency elected by the Company to verify all the information I have provided as well as any other information the Company deems relevant to my qualifications or suitability for employment. I also release from all liability any current or former employers, other entities (schools, etc), or persons (such as current or former supervisors, co-workers, etc) supplying information, and release you from all liability which might result from making the investigation.

I certify that all the information given in this application and in any attachments, supporting documents or interviews is (or will be) true, complete and accurate to the best of my knowledge. I understand and agree that any falsification, misrepresentations or omission, as well as any misleading statements or omissions, generally will result in denial of employments, withdrawal of any offer of employments or immediate termination, regardless of when and how discovered.

I understand that I may be required to submit to a pre-employment, post-offer physical exam or other medical inquiries, urinalysis and/or oral swab test for the presence of drugs and/or alcohol to determine if I am able to perform the essential functions of the position with or without a reasonable accommodation as a condition of my employment. I understand that the cost of any examinations or inquiries will be paid by the Company. I agree to such examinations and I authorize release of results to the Company and their use to evaluate my suitability of employment. I also release the Company from all liability arising out of or connected with any examinations, inquiries and/or testing.

I understand and agree that I may resign or be terminated without cause or notice, at any time, unless otherwise stated in a written employment contract. I also understand and agree that the CEO is the only person who will ever have the authority to agree to any other terms and/or to enter into such contracts, and that all such agreements for other terms of employment or contracts must also be signed by both parties. I also understand and agree that unless otherwise stated in a written employment contract, the Company may change, withdraw and interpret other policies (including wages, hours and working conditions) as it deems appropriate.

This application will only be considered for 90 days. I understand that if I have not been hired within this time period and still wish to be considered for employment, I must complete a new application.

I understand and agree that if I am hired the statements in these paragraphs will become a binding part of my employment relationship. I have read (or have been read to me in a language I understand) each of these statements. I have also reviewed all of the information provided in this application and in any attachments or supporting documents.

Please indicate if you are currently excluded, debarred or otherwise ineligible to be employed by a company that participates in federally funded heath care programs, specifically including but not limited to Medicare and Medicaid, federal government programs, or under state health care programs or laws.

Please initial your response above.

How did you hear about us?

If other, please specify.