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EMPLOYMENT APPLICATION
PERSONAL INFORMATION
First Name Middle Name Last Name
Other Names Used
Current Street Address City State Zip
Previous Address (if fewer than 5 years at current address) City State Zip
Mobile Phone Home Phone Personal Email
Position Applied for: Full-Time Part-Time Temporary On Call
Wage Expected ______________________________ Hourly Annually
How did you hear about this opportunity? Advertisement, please specify source: ________________________________________________________ Job Board, please specific name of site: _____________________________________________________ VCA Employee R e f e r r a l , p l e a s e i n d i c a t e n a m e :________________________________________________ VCA Website Acquisition/Merger
Have you ever been employed by VCA Inc. or any of its divisions including Antech, Sound, Camp Bow Wow, AVC (Canada)?
Yes (when and where?) No
Do you have any relatives working for VCA Inc. or any of its divisions?
Yes - Please indicate name and relationship No
Are you at least 18 years of age? Yes No
If hired, are you able to provide verification of your identity and legal right to work in the United States? Yes No
RECORD OF EDUCATION
School Name, City and State of School Course of Study, Major, or Specialty
Number of Years Completed
Did you graduate?
List Degree or Diploma
High School
College/University Graduate Other (trade tech, correspondence , military or professional credentials)
CONTINUED ON BACK
V C A I n c. will provide equal employment opportunities to all applicants without regard to an applicant's race, color, religion, gender, genetic information, national origin, age, veteran status, disability, or any other status or characteristic protected by law. VCA I nc. will provide reasonable accommodations to allow an applicant to participate in the hiring process (e.g., accommodation for a test or job interview) if so requested. All employment at VCA Inc. is “at will” and may be terminated at any time by either party.
1. EMPLOYMENT INFORMATION
Name of Employer
Start date End date
Job Title Phone Employer’s Address
Supervisor’s Name Starting Rate of Pay Ending rate of pay Supervisor’s Job Title Supervisor’s Phone or Email Reason(s) for leaving
Work performed
May we contact this employer for a reference or to verify information you have provided? Yes No (if no, please explain)
WORK HISTORY
Even if you are providing a résumé , please complete this section in its entirety, beginning with your most
recent work history. You may also include relevant volunteer experience.
2. EMPLOYMENT INFORMATION
Name of Employer
Start date End date
Job Title Phone
Employer’s Address
Supervisor’s Name Starting Rate of Pay Ending rate of pay
Supervisor’s Job Title Supervisor’s Phone or Email Reason(s) for leaving
Work performed
May we contact this employer for a reference or to verify information you have provided? Yes No (if no, please explain)
3. EMPLOYMENT INFORMATION
Name of Employer
Start date End date
Job Title Phone
Employer’s Address
Supervisor’s Name Starting Rate of Pay^ Ending rate of pay
Supervisor’s Job Title Supervisor’s Phone or Email Reason(s) for leaving
Work performed
May we contact this employer for a reference or to verify information you have provided? Yes No (if no, please explain)
PROFESSIONAL REFERENCES – List the names and contact information for three individuals (not relatives) who are
familiar with your work, especially individuals to whom you have reported. Note: If this position will be your first work
experience, then references may be teachers, community leaders, or other individuals who can attest to your character and
work ethic.
Name Position
Company Phone
Relationship to applicant Email
Name Position
Company Phone
Relationship to applicant Email
Name Position
Company Phone
Relationship to applicant Email
Is there anything about you or your connection with another person or business which could potentially interfere with your work at VCA Inc. or possibly create a conflict of interest? No Yes - Please explain fully
EMPLOYMENT APPLICATION CERTIFICATION
I hereby certify that the answers given by me to the foregoing questions and statements are
true and correct without reservation and hereby authorize VCA Inc. to verify same. If
employment is obtained under this application, I will comply with all orders, rules, and
regulations of the company. Unless otherwise noted in this document, I authorize VCA Inc.
to verify information I have provided in this application with my former employers and
educational institutions. If upon review, anything contained in this application is found to be
untrue, I understand that I will be subject to dismissal at any time during my period of
employment. I understand that, if hired, I may not hold other employment nor engage in other
activities that create a conflict of interest unless given permission in writing by a Senior
Leader or Executive Officer of VCA Inc.
________________________________ _________________________________
Applicant Signature Date
Rev. 5/
