NEO Hospice Job Application

Application for Employment
Northeast Ohio Hospice is an equal opportunity employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, citizenship, marital or veteran status, the presence of a disability or any other legally protected status.
Personal Information
Name

First NameMiddle InitialLast Name
Todays Date

MonthDayYear
Date
Present Street Address

Present Street Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Telephone
Alternate Phone
Cell Phone
Permanent Address (If different from above)

Permanent Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Email address
example@example.com
Are you under 18 years old? (If yes, you must provide a work permit.)

YesNo
Are you legally authorized to work in the United States? (Proof of eligibility and identity will be required if hired)

YesNo
Have you lived in the State of Ohio for the past five years?

YesNo
Position Desired
First Choice
Second Choice
Third Choice
How did you hear about NEO Hospice?
Have you ever worked at NEO Hospice before?

YesNo
Provide employment dates:
Have you ever applied to work here before?

YesNo
When:
If Applicable, current NEO Hospice employee name and your relationship to them:
Education

	Name and Location	Major Course of Study	Diploma/Degree	Did you graduate? (Yes/No)
High School
Undergraduate College
Graduate/Professional
Other (Specify)

What courses are you currently taking?
Professional Licenses and/or Certificates
Type
Organization or State Issues
Expiration Date
Number
Verification
Employment History

Begin with most recent position, and include the last three positions you have held.

Employment

	Company 1	Company 2	Company 3
Company Name
Dates Employed
Your Job Title
Salary
Address, City, Zip
Supervisor Name/Title
Phone Number
Reason for leaving
May we contact them for reference?
If no, why not?
Brief Description

Summarize periods of unemployment or periods not accounted for
How many hours per week are you available to work?

35-408-34As-need hours
Shift Preference:

1st Shift2nd Shift3rd ShiftOther
Are you available to work holidays?

YesNo
Are you available to work on weekends?

YesNo
References

Please enter three references from your past employment below who are supervisors, managers, directors or Director of Nursing and can speak to your skills and abilities

Type a question

	Reference 1	Reference 2	Reference 3
Name
Phone Number
Occupation
Relationship
Date/Time

Please read carefully and initial at the end of each statement
I certify that answers given herein are true and complete to the best of my knowledge, and understand and agree that any misrepresentation, falsification, or omission on my application or related papers, or made during any oral interviews may result in refusal of employment or shall be considered grounds for dismissal.
NEO Hospice may make an investigation of my history and may verify all data given in my application of employment, related papers, or oral interviews. This includes providing a set of fingerprint impressions for a criminal history check which is required by Senate Bill 160.I allow such investigation and release from liability NEO Hospice and/or any person or company giving or receiving such information. I agree that this document or a copy of this document will signify my consent to any background checks conducted by NEO Hospice.
I understand and agree that this application is not, and is not intended to be a contract of employment, and that if hired, my employment is at will, for no definite period, and may be terminated at any time without prior notice, without liability for wages, salary or any benefits except those earned up to the date of termination.
If employed by NEO Hospice, I agree to undergo medical examinations, including drug and alcohol testing, at any time at the option of NEO Hospice, and I also understand and agree that I will abide by its rules and regulations. If separated from employment from NEO Hospice for any reason, I authorize NEO Hospice Center to furnish any information to employment references and release from liability it and/or any person giving or receiving any such information.
I have read, understand, and agree to the above.
Signature

Clear
Date

MonthDayYear
Date
Reading Comprehension
Please read the following paragraph and answer the questions below as they apply to the paragraph.

Northeast Ohio Hospice promotes the hospice concept of caring and encourages and aids in the development of quality hospice programs forterminally ill patients and their families. We educate the public about hospice care and respond to the needs of the local community with hospiceservices that are consistent with the medical-moral teachings of the Roman Catholic Church.In fulfillment of our mission, we commit ourselves to these values: Respect, Hospitality, Community, Discovery of Potential and Celebration of Life.
Who is NEO Hospice inspired by
What does NEO Hospice continue
What does NEO Hospice provide to older adults
For whom does NEO Hospice have special concern
In fulfilling this mission what values do we commit ourselves to
What interests you about working at NEO Hospice Center
What made you go into your chosen profession? What makes you stay in it?
Is there anything else we should know about you that makes you the right candidate for the position for which you applied
Should be Empty:

Application for Employment

Personal Information

Position Desired

Education

Professional Licenses and/or Certificates

Employment History

References

Please read carefully and initial at the end of each statement

Reading Comprehension