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.
Applicant Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
YesNoOther, please explain:
PhoneEmail
Best Days & Time of Day to contact you?*
If hired, when are you available to start?*
YesNo

Military Record*
Yes, I have servedYes, I am currently servingNo
Please list Military Branch, Entry Rank, Seperation Rank, Seperation Date(s), Military occupation specialty as well as any specialized training and or service awards or commendations.

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.
YesNo
Please describe for what, when, and where*
YesNo
Please describe for what, when, and where*
YesNo
Please describe for what, when, and where*
YesNo
Please describe for what, when, and where*

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.
WeekdaysWeekendsDaysEveningsOther, please explain
YesNo
If you answered yes to the question regarding limiting your annual earnings, please list the maximum amount you wish to earn*
YesNo

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
Name*

First NameLast Name
Phone #*
Please enter a valid phone number.Format: (000) 000-0000.
Company Name, Address & Title *
Reference #2
Name*

First NameLast Name
Phone #*
Please enter a valid phone number.Format: (000) 000-0000.
Company Name, Address & Title *
Reference #3
Name*

First NameLast Name
Phone #*
Please enter a valid phone number.Format: (000) 000-0000.
Company Name, Address & Title *
YesNo

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.
Yes
Yes
Yes
If employed, I understand I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment; in addition, I must consent to drug testing, Family Care Safety Registry check, EDL check, and must accept all personnel policies of Pike County Health Department Home Health & Hospice as a condition of employment.*

Yes
Signature*

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Applicant Information*