Application for Employment

  • Application for Employment

  • Applicant Information*

    Please complete the following questions. Some pages are required and others can be skipped if the information is on a resume that can be uploaded on the last page.
  • Format: (000) 000-0000.
  • Do you have a valid drivers license & a reliable form of transportation?*
  • What is the best way to contact you?*
  • Do you anticipate uploading a resume along with submission of this application? (If you check "Yes" you will be required to upload the document before you can submit)*

  • Employment Desired*

  • Position Desired*
  • Employment Preference*
  • How did you hear about this job opening?*

  • Education & Training

    Please review the following questions. If this information can be found on your resume please check the appropriate box at the bottom of this page and upload your resume on the last page.

  • High School

  • High School*

  • College

  • Did you attend college?*
  • Type of Degree Earned*

  • Additional Training & Certifications

  • Do have any additional Special Trainings or Certifications earned?*

  • Other

  • Professional Licenses

  • Do you have any Professional Licenses?*

  • License #1

  • License #2

  • License #3

  • Are the above questions listed on your resume?*

  • Military Record*

  • Have you or are you currently serving in the military?*

  • Crime Disclosure*

    Conviction of a criminal offense or a plea of guilt will not necessarily preclude your employment. By signing this application for employment you agree to sign a consent form required by Section 43.540 RSMo so that the agency may request a criminal records review. You should be aware that your failure to knowingly disclose any criminal history is a Class A Misdemeanor.
  • Have you ever been convicted of a crime?*
  • Have you ever plead guilty to a crime?*
  • Have you ever had a criminal background check?*
  • Has the Division of Aging ever placed you on the Employee Disqualification List (EDL)?*

  • Availability

    Please inform us the days and times you are available to work. Please review the following questions. If this information can be found on your resume please check the appropriate box and upload your resume on the last page.
  • Please choose all that apply*
  • Do you limit your annual earnings due to Social Security or other reasons?*
  • Are the above questions listed on your resume?*

  • References

    Please list three references who are not friends, relatives, or former employers. Please review the following questions. If this information can be found on your resume please check the appropriate box and upload your resume on the last page.

  • Reference #1

  • Format: (000) 000-0000.

  • Reference #2

  • Format: (000) 000-0000.

  • Reference #3

  • Format: (000) 000-0000.
  • Are the above questions listed on your resume?*

  • Employment History

    Please list current, or most recent employer first and all others in reverse chronological order. Up to 5 employers can be listed, if more is needed please upload attachment or add to comments section on the next page. Please review the following questions. If this information can be found on your resume please check the appropriate box and upload your resume on the last page.

  • Employer #1

  • Format: (000) 000-0000.
  • May we contact for reference?*

  • Employer #2

  • Format: (000) 000-0000.
  • May we contact for reference?*

  • Employer #3

  • Format: (000) 000-0000.
  • May we contact for reference?*

  • Employer #4

  • Format: (000) 000-0000.
  • May we contact for reference?*

  • Employer #5

  • Format: (000) 000-0000.
  • May we contact for reference?*
  • Are the above questions listed on your resume?*

  • Other

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  • Application Disclosure*

  • Pike County Health Department Home Health & Hospice does not discriminate in hiring or any other decision on the basis of race, color, religion, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

    Pike County Health Department Home Health & Hospice is an Equal Opportunity Employer.

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