Personal Information
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
List any other names which you are known as:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Social Security
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you 18 years old or older?
Yes
No
Desired Employment
Have you ever applied or worked for Hospice of Marshall County?
Yes
No
Position applying for:
Date you are available
-
Month
-
Day
Year
Date
Salary Desired:
Are you employed now?
Yes
No
IF SO, may we contact your current employer?
Yes
No
Are you available to work weekends?
Yes
No
Are you available to work overtime?
Yes
No
Which are you looking for?
Regular Full-time work
PNR casual as needed
Can you present evidence of your legal right to work in the U.S.?
Yes
No
Would you have a reliable means of transportation to and from work?
Yes
No
Do you have a valid driver’s license?
Yes
No
Who referred you to this agency?
Ad for job opening
Employment agency
Walk in
Unemployment Office
Friend/Family
Employee
Name of Family/Friend referral
Name of Employee referral
Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodation? (If no, please select "other" and describe the functions that cannot be performed.)
Yes
Other
Education: Fill out each year of schooling and more will appear to be filled out.
Highschool: Name & Location of School
Highschool: # of years completed
Highschool: Did you graduate?
Yes
No
Highschool: Degree / Diploma
College / University: Name & Location of School
College / University: # of years completed
College / University: Did you graduate?
Yes
No
College / University: Degree / Diploma
Vocational / Business: Name & Location of School
Vocational / Business: # of years completed
Vocational / Business: Did you graduate?
Yes
No
Vocational / Business: Degree / Diploma
Certifications: License Number
Certifications: Name & Location of School
Certifications: # of years completed
Certifications: Did you graduate?
Yes
No
Certifications: Degree / Diploma
Former Employers
Name of Present or Past Employer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Start Date
-
Month
-
Day
Year
Date
Leave Date
-
Month
-
Day
Year
Date
May we contact your supervisor?
Yes
No
Starting Wage
Final Wage
Supervisor (Name & Title):
Telephone #:
Please enter a valid phone number.
Format: (000) 000-0000.
Description of Job Duties:
Reason for Leaving:
*
Name of Present or Past Employer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Start Date
-
Month
-
Day
Year
Date
Leave Date
-
Month
-
Day
Year
Date
May we contact your supervisor?
Yes
No
Starting Wage
Final Wage
Supervisor (Name & Title):
Telephone #:
Please enter a valid phone number.
Format: (000) 000-0000.
Description of Job Duties:
Reason for Leaving:
*
Name of Present or Past Employer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Start Date
-
Month
-
Day
Year
Date
Leave Date
-
Month
-
Day
Year
Date
May we contact your supervisor?
Yes
No
Starting Wage
Final Wage
Supervisor (Name & Title):
Telephone #:
Please enter a valid phone number.
Format: (000) 000-0000.
Description of Job Duties:
Reason for Leaving:
*
Name of Present or Past Employer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Start Date
-
Month
-
Day
Year
Date
Leave Date
-
Month
-
Day
Year
Date
May we contact your supervisor?
Yes
No
Starting Wage
Final Wage
Supervisor (Name & Title):
Telephone #:
Please enter a valid phone number.
Format: (000) 000-0000.
Description of Job Duties:
Reason for Leaving:
*
Name of Present or Past Employer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Start Date
-
Month
-
Day
Year
Date
Leave Date
-
Month
-
Day
Year
Date
May we contact your supervisor?
Yes
No
Starting Wage
Final Wage
Supervisor (Name & Title):
Telephone #:
Please enter a valid phone number.
Format: (000) 000-0000.
Description of Job Duties:
Reason for Leaving:
*
Special skills or abilities as the result of service in the military:
Have you ever been convicted of a criminal offense (felony or misdemeanor)?
Yes
No
Have you ever been
Yes
No
If yes, state the nature of the crime(s), when and where convicted, and disposition of the case(s):
Special licenses or certifications:
Other experience, training, qualifications, or skills that you feel are relevant to to employment with this company:
Professional references
Name
Title
Company
Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Years Associated
Name
Title
Company
Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Years Associated
Name
Title
Company
Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Years Associated
Authorizations - read and initial each paragraph and sign below:
Please check below
TRUTHFULNESS OF APPLICATION: I certify that the facts set forth in this employment application are true and complete to the best of my knowledge. I understand that the misrepresentation or omission of any material fact may result in denial of employment or termination of my employment.
AUTHORIZATION TO INVESTIGATE: I authorize any of the persons or organizations referenced in this application to give the Company any and all information concerning my previous employment, education, or any other information they might have, with regard to any of the subjects covered by this application, and release all such parties from the liability for any damage that may result from furnishing such information. I authorize the Company to request and receive such information.
AT-WILL RELATIONSHIP: I understand and agree that if I am offered employment with the Company it will be on an “at-will” basis. This means that either I or the Company may terminate the employment relationship at any time for any reason, with or without cause with or without prior notice. I further understand that the “at-will” nature of my employment with the Company is an aspect of employment that cannot be modified or changed, except by a written agreement signed by the chief executive officer of the Company. I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company.
SEARCH OF PUBLIC RECORDS: Should a search of public records—including records of an arrest, indictment, conviction, civil judicial action, tax lien, or outstanding judgment—be conducted by internal personnel employed by the Company, I am entitled to copies of any such public records obtained by the Company unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have checked the box below.
I waive receipt of a copy of any public record described in the above paragraph.
Signature
Date
-
Month
-
Day
Year
Date
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