Are You At Least 18 Years Old?
Yes No

Office Skills

Not Applicable
Multi-line Phones
Postage Meter
Facsimile Machine
Adding Machine
Customer Service Experience
Typing - WPM
Data Entry - CWPM
Other:

Field Skills

Not Applicable
Hospice Experience
Home Health Experience
IV Infusions
Ambulatory Infusion Pump
Implanted Catheters
Case Management
Other:

Computer Skills

Not Applicable
MS Word
MS Publisher
MS Access
Excel
Windows
PowerPoint
Other:

Upon the submission of this application, I represent that all of the information now or hereafter given by me in support of my application is true and complete. I authorize you to verify any of the information concerning my background, including but not limited to, my employment, driving record, education, criminal history, or medical history (post-offer only), with the appropriate individuals, companies, institutions or agencies, and I authorize them to release such information as you require, including my prior disciplinary employment record, without any obligation to give me written notice of such disclosure. I also authorize VitalCare to release any information requested by any of my prospective or subsequent employers without any written notification of such disclosure. I hereby release VitalCare and them from any liability whatsoever as a result of any such inquiries and disclosures and this release from liability does not waive or prohibit an individual from filing a charge of discrimination under such laws enforced by the EEOC. I agree that any false information in support of my application may subject me to discharge at any time during the period of my employment.

I understand that, under Michigan Law, disabled employees and applicants may request an accommodation of their disability by notifying VitalCare in writing of the need for accommodation within 182 days of the date of the disabled individual knows or should know that an accommodation is needed. This requirement does not apply to an individual’s right under the Americans with Disabilities Act. Failure to properly notify VitalCare may preclude any claim that the employer failed to accommodate the disabled individual.

I understand that VitalCare reserves the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought into or taken out of VitalCare. I understand that refusal to submit to a urinalysis or blood test, when requested to do so, may result in termination of my employment.

I agree that either party may terminate the employment relationship, with or without cause, at any time, and I further agree that this arrangement may only be altered in writing directed to me personally and signed by the president of VitalCare. I agree that I shall be bound by the other rules, policies, regulations and terms and conditions of employment of VitalCare as they are from time to time changed, and no additional obligations can be imposed on VitalCare except those which have been acknowledged in writing, by the president or his designated representatives.

I hereby authorize VitalCare to deduct from each and every period of my pay any amounts necessary to offset any damages caused by me or the value of property or money entrusted to me by, or owed by me to, VitalCare during the course of my employment.

I agree that any action or suit against VitalCare, its agents or employees, arising out of my employment or termination of employment, including, but not limited to, claims arising under State, but not Federal, civil rights statutes, must be brought within 180 days of the event giving rise to the claims or be forever barred. I waive any limitation periods to the contrary. I further agree that if I should bring any non-statutory action or claim arising out of my employment against VitalCare, in which VitalCare prevails, I will pay to VitalCare any and all such costs incurred by VitalCare in defense of said claims or actions, including attorney fees.