SHH Employment Application Form

Positions Applied For:

Specify Shifts You Are Available to Work:

DayNightEveningWeekend

Will Accept Employment:

Full TimePart TimePRN

Salary Expected

Positions Applied For:

Today's Date

Date

Are you at least 18 years of age?

YesNo

Specify Shifts You Are Available to Work:

DayNightEveningWeekend

Will Accept Employment

Full TimePart TimePRN

Salary Expected

Name:*

First NameLast Name

Birth Date

MonthDayYear

Type a question

Type option 1Type option 2Type option 3Type option 4

Phone Number:*

Area CodePhone Number

Alternate Phone Number

Area CodePhone Number

E-mail Address:

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Education

High School Graduated

High School City/State

High School Dates Attended

College 1 Attended

College 1 Dates Attended

College 1 Graduated Yes/No

College 1 Degree

College 1 Major

College 2 Attended

College 2 Dates Attended

College 2 Graduated Yes/No

College 2 Degree

College 2 Major

Trade School (Please list all information of school and education details)

Other Schooling (Please list any other schools or education not listed above)

Are you currently enrolled in school? If yes, please list course of study.

List any professional/occupational licenses including state and expiration date:

References

Please list two (2) references that are familiar with your work life.

How were you referred to us?*

Others:

Upload Resume:

Upload a File

Job History, Skills & Training

Previous Employer 1

Previous Employer 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Previous Employer 1 Job Title

Previous Employer 1 Phone

Area CodePhone Number

Previous Employer 1 Salary

May we contact?

Previous Employer 1 Reason For Leaving

Previous Employer 2

Previous Employer 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Previous Employer 2 Phone

Area CodePhone Number

Previous Employer 2 Job Title

Previous Employer 2 Salary

May we contact?

Previous Employer 2 Reason For Leaving

Previous Employer 3

Previous Employer 3 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Previous Employer 3 Phone

Area CodePhone Number

Previous Employer 3 Job Title

Previous Employer 3 Salary

May we contact?

Previous Employer 3 Reason For Leaving

Describe your skills:*

Have you ever been convicted of a crime? If yes, please explain.

Do you need accomodation (covered under the Americans with Disabilities Act) to successfully do the work for which you have qualified? If yes, please describe:

Date Available for work:

Reference 1

Name:*

First NameLast Name

Phone Number*

Area CodePhone Number

Years Known:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Reference 2

Name:*

First NameLast Name

Phone Number*

Area CodePhone Number

Years Known:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Non-Discrimination Policy
Sanctuary Hospice is an equal opportunity employer and will not discriminate on the basis of age, sex, marital status, race, creed, color, religion, national origin or handicap in accordance with Title VI of the Civil Rights Act of 1964 and all other federal guidelines.

Certification of Applicant
I hereby certify that all information given by me in this application or other documents is true in all aspects. I understand that misrepresentation or omission of facts will result in cancellation of my consideration for employment or dismissal if employed. I further certify and agree to abide by and comply with all of the rules and policies of Sanctuary Hospice

Authorization for Release of Information
I hereby consent to an inspection of records and documents in the possession of former employers that may be material to an evaluation of my employment. I hereby release from any liability all persons, and organizations, institutions and former employers who provide information to Sanctuary Hospice in good faith and without malice, concerning my competence, ethics, character, ability to work with others, and other qualifications for employment, including what may be considered privileged or confidential information.

Signature

Date