Online Job Application Form

Application of Employment

Please Fill Out the Form Below to Submit Your Job Application!
Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Applied For*
Earliest Possible Start Date*

MonthDayYear
Date
Desired Salary*
Type of work desired*
Full time, Part Time, or PRN.
Are you willing to work Overtime?
If Salary, select "N/A".
If under the age of 18, can you produce the necessary work certificate at the time of employment?*
If over 18, select "N/A"
Have you ever applied for a job with us before?*
If "Yes", when did you apply?

MonthDayYear
With the past ten (10) years, have you been convicted of a felony? (Do not include convictions that were sealed, eradicated, erased, expunged; Convictions that resulted in referral to a diversion programs; or marijuana-related convictions that re more than two (2)year old).*
If "Yes", please explain so that individual circumstances can be considered.
Note:
- Criminal Convictions will not automatically disqualify an applicant from a particular job. The company will consider the nature of the crime, its seriousness, whether the conviction(s) substantially relates to the position’s functions and qualifications, the frequency of convictions, the applicant’s age at the time of conviction, the time elapsed since the date of conviction or completion of jail sentence, the applicant’s entire work and educational history, and employment references and recommendations.
- An ex-offender who is denied employment may, upon written request, receive a statement of the reason(s) for denial within 30 days of the applicant’s request for such information.
California Applicants: This does not include convictions under California Health & Safety code §§ 11357 (a or b), 11360 (c or d), 11364, 11365, or 1150 related to marijuana which occurred two or more years before the instant application.

Connecticut Applicants: Applicants are not required to disclose the existence of any arrest, criminal charge, or conviction, the records of which have been erased. Criminal records subject to erasure are records pertaining to finding of delinquency or the fact that the child was member of a family with service needs, and adjudication as a youthful offender, a criminal charge that has been dismissed or knolled (not prosecuted), a criminal charge for which the person was found not guilty, or conviction for which the offender received an absolute pardon. Any person whose criminal records have been erased is deemed to have never been arrested within the meaning of the law as it applies to the particular proceedings that have been erased, and may so swear under oath.

Massachusetts Applicants: Applicants for employment with a sealed record on file with the Massachusetts Commissioner of Probation may answer “No record” with respect to all inquiries relating to prior convictions.
Have you ever initiated an act of violence in the workplace?*
If "Yes", please explain so that individual circumstances can be considered:
A "Yes" Answer will not necessarily disqualify you from employment consideration.
List special technical skills that you feel qualify you for the job which you are applying:
e.g.: computer programming / language software, equipment operation, special tools of machines, etc.

Education

	Institution Name and Location	Course of Study	Graduated?	# Years Completed	Degree / Major
High School
College
Bus./Tech./Trade or Post-College

Honors Received?

Work Experience

Start with your present of last place of employment. You may include any verifiable work performed on a volunteer basis, internships or military service.
Work Experience 1*
Start Date*

MonthDayYear
Work Experience 1
End Date*

MonthDayYear
Work Experience 1
Work Experience 2*
Start Date*

MonthDayYear
Work Experience 2
End Date*

MonthDayYear
Work Experience 2
Work Experience 3
Start Date

MonthDayYear
Work Experience 3
End Date

MonthDayYear
Work Experience 3
References
Reference 1*
Reference 2
Upload Resume

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Any Other Documents to Upload

You can share cover letter, certificates, diplomas, etc.
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Application Certification Statement
I understand and agree that if driving is a requirement of the job for which I am applying, my employment and /or continued employment is contingent on possessing a valid driver’s license and auto mobile liability insurance in an amount equal to the minimum required by the state where I reside.

I understand that the Company may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state, and local law, If the Company has such a program and I am offered a conditional offer of employment, I understand that if pre-employment (post-offer) drug and or alcohol test is positive, the employment offer may be withdrawn. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law, may be subject to urinalysis and /or blood screening or other medically recognized tests designed to detect the presence of alcohol or controlled drugs. If employed, I understand that the taking of alcohol and or drug tests is a condition of a continual employment and I agree to undergo alcohol and drug testing consistent with the company’s policies and applicable federal, state, and local law.

If Employed by the Company, I understand and agree that the Company, to extent permitted by federal, state, and local law, may exercise its right, without prior warning or notice, to conduct investigations of property Including, but not limited to, files, lockers, desks, vehicles, and computers, and, in certain circumstances, my personal property.

I understand and agree that as a condition of employment and to the extent permitted by federal, state, and local law, I may be required to sign a confidentiality, non-compete, and/or interest statement.

I certify that all the information on this application, my résumé, or any supporting documents is complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal.

I understand that neither this Application nor any communication by a management representative is intended to create or does create a contract of employment, offer promises or employment. I acknowledge that if hired by the company, employment is on an at-will basis. This means the company is free to terminate my employment at any time, with or without cause or advance notice, in accordance with state law and acceptance of employment is not a contract of employment for any specified time, similarly, I am free to terminate my employment with the company at any time for any reason. This at-will provision maybe modified or waived only in a written agreement signed by an authorized representative of the company and me. I agree to conform to the rules and regulations of the company and I understand that the company has complete discretion to modify such rules and regulations at any time, except that it will not modify its policy of employment at-will.

I authorize the Company or its agents to confirm all statements contained in this application and/or résumé as it relates to the position I am seeking and to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the background investigation.

I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the above mentioned information, I hereby release discharge and hold harmless, to the extent permitted by federal, state, or local law, any party delivering information to the Company or its duty authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as result of the delivery or disclosure of the above requested information. I hereby release from liability the Company and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information.

If hired by this company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the united stated, I also understand this company employs only individuals who are legally eligible to work in the United States.
Applicant Signature*

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First Health Hospice, LLC is an equal opportunity employer. Applicants are considered for positions without regard to race, religion, sex, national origin, age, disability, or any other consideration made unlawful by applicable federal, state of local laws.
Should be Empty:

Application of Employment

Work Experience

References

Application Certification Statement