Good Samaritan Hospice - Application for Employment

Application for Employment
We celebrate diversity and are committed to creating an inclusive environment for all employees. We do not discriminate on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, parental status, military service, or other non-merit factor.
Personal Information
Name:*

First NameMiddle NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Date
Present Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.
Is this a cell phone?*

YesNo
May we text you?*

YesNo
Email*
example@example.com
Preferred method of contact:*

Educational Information:
High School:
School Name:
Phone Number of School:
Please enter a valid phone number.
Address of School:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates Attended:
Graduated?

YesNo
Higher Education
College:
School Name:
Phone Number of School:
Please enter a valid phone number.
Address of School:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates Attended:
Name While Attending:
Degree Completed:
Subject(s) Studied:
College:

Additional Higher Education
School Name:
Phone Number of School:
Please enter a valid phone number.
Address of School:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates Attended:
Name While Attending:
Degree Completed:
Subject(s) Studied:
Trade or Business School:
School Name:
Phone Number of School:
Please enter a valid phone number.
Address of School:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates Attended:
Name While Attending:
Degree Completed:
Subject(s) Studied:

Special Skills
Subjects of Special Study/Special Training/Other Skills/Certifications:
Former Employers

List last ten years, starting with most recent
From:*

MonthDayYear
Date
To:*

MonthDayYear
Date
Former Employer:*
Business Address:
Business Phone Number:*
Supervisor Contact Information:*
Name, Email and Phone Number
Beginning Salary:*
Ending Salary:*
Position(s) Held:*
Reason(s) for Leaving:*
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Former Employer:
Business Address:
Business Phone Number:
Supervisor Contact Information:
Name, Email, and Phone Number
Beginning Salary:
Ending Salary:
Position(s) Held:
Reason(s) for Leaving:
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Former Employer:
Business Address:
Business Phone Number:
Supervisor Contact Information:
Name, Email, and Phone Number
Beginning Salary:
Ending Salary:
Position(s) Held:
Reason(s) for Leaving:
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Former Employer:
Business Address:
Business Phone Number:
Supervisor Contact Information:
Name, Email, and Phone Number
Beginning Salary:
Ending Salary:
Position(s) Held:
Reason(s) for Leaving:
References

Give the names of three persons, not related to you, whom you have known at least one year.
Name:*
Contact Information:*
Email and Phone Number
Relationship:*
Years Known:*
Name:*
Contact Information:*
Email and Phone Number
Relationship:*
Years Known:*
Name:*
Contact Information:*
Email and Phone Number
Relationship:*
Years Known:*
Additional Questions
Are you legally authorized to work in the USA?*

YesNo
Do you require accommodation to perform the tasks of your job?*

YesNo
Is there anything that would prevent you from fulfilling the position for which you are applying?*
Please briefly explain what interests you about hospice work.*
Resume Upload:

Cancelof

Driving Record
Minimum driving standards for Good Samaritan Hospice staff that drive as a normal part of their job description requires that prospective employee have (1) no more than three moving violations or more than one chargeable accident, (2) no major convictions (drunk, drug, or reckless driving) and (3) no license suspensions or revocations related to the above parameters within the past 36 months. Applicants who fail to meet these driving requirements may be ineligible for employment.
Sworn Statement Regarding Criminal Activity
Virginia Hospice Regulations require that employees working for hospice provide a sworn statement or affirmation disclosing any criminal convictions (This includes: misdemeanors, felonies, and pleading no contest to a charge) or any pending criminal charges, whether within or outside of the Commonwealth of Virginia.
Have you been convicted or are pending conviction of any criminal charges?

YesNo
This is my sworn statement that I have never been convicted of ANY criminal charge and I am NOT subject to any criminal offense within or without Virginia.
Please enter your initials if this applies
This is my sworn statement that I have been convicted or have pending the following criminal charges.
Please enter your initials if this applies
Date of the Offense:

MonthDayYear
Date
Description of the Offense:
Disposition:
Date of Disposition:

MonthDayYear
Date
Authorization
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if I am employed, any falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to provide Good Samaritan Hospice with any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I understand that if I am extended an offer of employment, it will be conditional based on completing and passing all pre-employment requirements. I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT ARE NOT INTENDED TO CREATE A CONTRACTUAL AGREEMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF HIRED, I UNDERSTAND IT IS AN AT WILL AGREEMENT AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE OR NOTICE. I acknowledge that Good Samaritan Hospice performs pre-employment, random, and for cause drug screening and that I must pass this screening to be eligible for employment/continued employment. I have read, understand, and by my signature consent to these statements.
Signature:*

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Printed Name:*

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Date*

MonthDayYear
Date
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Application for Employment

Personal Information

Employment Desired

Educational Information:

High School:

Higher Education

College:

College:

Trade or Business School:

Special Skills

Former Employers

References

Additional Questions

Driving Record

Sworn Statement Regarding Criminal Activity

Authorization