Application for Employment 2024

Application for Employment An Equal Opportunity Employer
Date: Our Hospice of South Central Indiana is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, nationality or nation of origin, disability or handicap, or veteran status.

TO THE APPLICANT: Thank you for your interest in employment. Please provide all information requested to be sure all your qualifications are considered. Interviews and selections are made on the basis of qualifications. This application for employment will not be considered unless fully completed.
Today’s Date*

MonthDayYear
Date
Legal First Name*
Middle Name
Last Name*
Address*

Street Address

Address 2

CityState / Province

Postal / Zip Code
Telephone Number: *
If no phone number, how may we contact you?
Email*
example@example.com
Date You Can Start Work*

MonthDayYear
Date
Which of the following schedules are you available?

1st2nd3rdPart TimeFull TimeTemporaryWeekendsOvertimeOn Call
Expected Pay*
What position are you applying for: *
If you are interested in other areas, please list them below:
Are you 18 yrs. of age or older? If not, employment is subject to verification of minimum legal age*

YesNo
Did anyone refer you to Our Hospice?*

YesNo
If yes, Name of Employee
Have you worked for us before?*

YesNo
If yes, please provide dates and position:
Relatives employed by us:
Relationship
Department
Professional Licenses/ Certifications
Type of License / Certification*
License / Certification No.*
Licensed / Certified in Indiana?

YesNo
Do you have an application in process for an Indiana License/Certification?

YesNo
If yes, Please Enter Date of Application

MonthDayYear
Date
License Certified elsewhere other than Indiana?
State or Country
Has your License ever been revoked?*

YesNo
If yes, Why?
Has your License/Certification every been under review?*

YesNo
If Yes, Why?
Record of Education
Highschool / GED*
Name and Address
Graduated?*

YesNo
College
Name and Address
Course of Study / Degree
Graduated?

YesNo
Post - Graduate
Name and Address
Course of Study / Degree
Graduated?

YesNo
List skills, experiences or qualifications which would especially fit you for the position you are applying for.*
Proof of Work Eligibility

Pursuant to the Immigration Reform and Control Act of 1986, all applicants, upon being made an offer of employment, must produce documents which are specified by the Federal Government establishing their identity and authorization for employment in the United States. These documents must be produced no later than seventy-two 72 hours after commencement of employment. You will be required to sign form I-9 issued by the Federal Government verifying, under oath, your employment authorization.
If you are hired, can you provide proof that you are eligible to work in the United States?*

YesNo
Have you been the subject of any adverse action(s) by any duly authorized sanctioning or disciplinary agency (such as the Office of the Inspector General or a state licensing board) for either conduct-based or performance-based actions?*

YesNo
If Yes, Explain:
Have you ever been convicted of a crime other than a minor traffic offense, or are you now under pending investigation for charges of violation of criminal law?*

YesNo
If yes, please explain each conviction or pending investigation, giving dates, crime, and court in which you were convicted: A conviction will not necessarily automatically disqualify you for employment. Rather, such factors as age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered.
Date of Conviction

MonthDayYear
Date

List Three Professional References (other than family and friends):*

	Name	Phone	How Do You Know This Person?

May we contact your present employer?*

YesNo
Employment History

Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer back to the last seven years.
Company Name*
Job Title & Work Description*
Telephone
Company Address*
Employed (Month and Year) From*
To*
Name of Supervisor and Title*
Annual or Hourly Pay Start
Last
Reason for Leaving*
Company Name
Job Title & Work Description
Company Address
Telephone
Employed From ( Month and Year)

MonthDayYear
Date
To
Name of Supervisor and Title
Annual or Hourly Pay Start
Last
Reason for Leaving
Company Name
Job Title & Work Description
Telephone
Company Address
Employed (Month and Year) From
To
Name of Supervisor and Title
Annual or Hourly Pay Start
Last
Reason for Leaving
Company Name
Job Title & Work Description
Telephone
Address
Employed (Month and Year) From
To
Name of Supervisor and Title
Annual or Hourly Pay Start
Last
Reason for Leaving
Have you ever been discharged from a job?*

YesNo
If yes, explain:
Please Read and Initial Each of the Following Statements. This Application is Invalid Without Your Initials and Signature Below.
ACCURACY OF INFORMATION PROVIDED AND SIGNIFICANCE OF THIS APPLICATION: I certify that all information on this application is correct and true and I understand that any misrepresentation or willful omission of material facts will be sufficient reason for the rejection of my application for employment, or if employed, my immediate discharge. I understand that this application is not a contract, offer, or promise of employment and that, if hired, I will be able to resign at any time for any reason and that the employer can likewise terminate my employment at any time, with or without cause. I also understand that while personnel policies, programs, and procedures may of necessity change from time to time, my status as an at will employee, if I am hired, is not subject to change absent a written agreement signed by the president of the employing organization, or designated authorized representative. I have read, understand, and agree to the above statements. (please initial here)*
PRE-HIRE DRUG TESTING AND POST-OFFER PRE-EMPLOYMENT MEDICAL EXAMINATION: I understand that this employer requires all job applicants to successfully pass a substance abuse test as a term and condition of an offer of employment. I further understand that I will be required to sign a test consent form and that my failure or refusal to do so will result in denial of employment. If the results of such tests indicate the presence of any illegal, controlled, or unauthorized drugs in my blood or urine, I will not be eligible for employment. I further understand that any job offer made is conditioned on the satisfactory outcome of a medical examination required for all employees, which would be conducted at the employer’s expense before employment would begin.
I have read, understand and agree to the above statements. (please initial here)*
DRUG FREE WORKPLACE COMPLIANCE: I understand that the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance on company premises or while conducting company business off company premises is absolutely prohibited. If employed by this employer, I agree as a condition of employment to abide by the terms of the Drug-Free Workplace Act of 1988 and any policies relating to this Act and to report any conviction under a criminal drug statue for violations occurring on or off company premises while conducting company business within five (5) days after such conviction. I further understand and agree that if I am employed, I may be required to submit to alcohol / drug testing under circumstances giving rise to reasonable suspicion of alcohol / drug use during my employment and that my refusal to submit to such testing is grounds for immediate termination of my employment. I have read, understand and agree to the above statements. (please initial here)*
AUTHORIZATION TO INVESTIGATE BACKGROUND: The employer, in considering my application for employment, may verify the information set forth on this application and obtain additional information relating to my background. I authorize all persons, schools, companies, law enforcement agencies, and former employers to supply this employer any information concerning my background and consent to the release of such information. I authorize this employer to investigate all information and release this employer and all persons, schools, companies, corporations, law enforcement agencies, and former employers from all liability and responsibility for furnishing any information concerning my background or confirming the information in this application. I further understand that any job offer made is conditioned on the satisfactory outcome of a background check required for all employees, which would be conducted at the employer’s expense before employment would begin. I have read, understand and agree to the statements above. (please initial here)*
REFERENCE RELEASE: I authorize Our Hospice of South Central Indiana and any parties they engage to make confidential inquiries and investigations covering my background (to include present and previous employment, present and previous education, police department records, court records, and personal references) as a condition for employment. I hereby release Our Hospice of South Central Indiana, Inc., its agents, employees, and designees (including those contracted by these parties) from and for any and all liability arising from such inquiries and investigations.*

Clear
EXPIRATION DATE OF EMPLOYMENT APPLICATION: I understand that this application is good for six (6) months from today’s date. If I still desire a position with this employer after this expires, it will be my responsibility to complete a new application and submit it for consideration. Otherwise, this employer will not consider me for employment after this application expires. I understand that completion of this application for employment form does not guarantee that I will be employed by this employer. I have read, understand, and agree to the statement above. (please initial here)*
Initials
Date of Application*

MonthDayYear
Date
Signature*

Clear
Please upload your current Resume or CV

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Should be Empty:

Application for Employment An Equal Opportunity Employer

Professional Licenses/ Certifications

Record of Education

Proof of Work Eligibility

Employment History