Gateway Hospice Application for Employment

Date Of Application

MonthDayYear

Position Applying For

Referral Source

If Other, Specify

If Employee Referral, name of Employee

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone Number

Area CodePhone Number

Cell Phone Number

Area CodePhone Number

E-mail

When is the best time to contact

May we contact you at work

If yes, work number and best time to call

Area CodePhone Number

:HourMinutesAM/PM Option

If you are under 18 and it is required, can you furnish a work permit

Have you submitted an application with Gateway Hospice before?

If yes please give date(s) and position(s) applied for

Have you ever been employed at Gateway Hospice before?

If yes, From when

MonthDayYear

To when

MonthDayYear

Are you legally eligible for employment in this country?

Date available to start work

MonthDayYear

Desired salary

Type of employment desired

Willing to relocate if job requires?

Will you travel if the job requires it?

Are you able to meet the attendance requirements of this position?

Willing to work overtime, if required?

If not willing to work overtime, please explain why below

If you have a professional license is it current?

Has it ever been excluded?

Do you have a clean driving record for the past two years? (No points or suspensions)

Have you signed a Non-Compete or Non-Solicitation agreement, etc. that would limit your ability to perform the duties of the job in which you are applying?

Driver's License Number if driving is essential to job function

Do you have reliable transportation if applying for a field position?

Upload Your Resume (Optional)

Upload a File

EMPLOYMENT HISTORY

Starting with your most recent employer, assignments or volunteer activities provise the following information. Please note: Reference checks may include those you list in your employment history.

EMPLOYER #1

Employer Name

Employer Phone Number

Area CodePhone Number

Dates Employed

From

MonthDayYear

To

MonthDayYear

Employer Address

Starting Job Title

Starting Compensation

Starting Amt.

Ending Job Title

Ending Compensation

Ending Amt.

Reason For Leaving

Immediate Supervisor and Title

May we contact for reference?

Summary of work performed and job responsibilities

EMPLOYER #2

Employer Name

Employer Phone Number

Area CodePhone Number

Dates Employed

From

MonthDayYear

To

MonthDayYear

Employer Address

Starting Job Title

Starting Compensation

Starting Amt.

Ending Job Title

Ending Compensation

Ending Amt.

Reason For Leaving

Immediate Supervisor and Title

May we contact for reference?

Summary of work performed and job responsibilities

EMPLOYER #3

Employer Name

Employer Phone Number

Area CodePhone Number

Dates Employed

From

MonthDayYear

To

MonthDayYear

Employer Address

Starting Job Title

Starting Compensation

Starting Amt.

Ending Job Title

Ending Compensation

Ending Amt.

Reason For Leaving

Immediate Supervisor and Title

May we contact for reference?

Summary of work performed and job responsibilities

SKILLS and QUALIFICATIONS

Summarize any special training, skills, licenses, and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying:

EDUCATIONAL BACKGROUND

School #1

School Name

Years Completed

Level Completed

GPA/Class Rank

Major

Minor

School #2

School Name

Years Completed

Level Completed

GPA/Class Rank

Major

Minor

School #3

School Name

Years Completed

Level Completed

GPA/Class Rank

Major

Minor

REFERENCES

List name and telephone numbers of three (3) business/work references that are not related to you and are not previous supervisors. If not applicable, list three (3) school or personal references that are not related to you.

REFERENCE #1

Name

Title

Relationship

Phone Number

Area CodePhone Number

Years known

REFERENCE #2

Name

Title

Relationship

Phone Number

Area CodePhone Number

Years known

REFERENCE #3

Name

Title

Relationship

Phone Number

Area CodePhone Number

Years known

REFERENCE #4

Name

Title

Relationship

Phone Number

Area CodePhone Number

Years known

ADDITIONAL INFORMATION

List professional trade, business, or civic associations and any offices held. Exclude memberships that would reveal race, color, religion, sex, national orgin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similiarly protected status.

Organization #1

Organization

Offices held with above organization

Organization #2

Organization

Offices held with above organization

Organization #3

Organization

Offices held with above organization

Organization #4

Organization

Offices held with above organization

List special accomplishments, publications, awards, etc.

Exclude memberships that would reveal race, color, religion, sex, national orgin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similiarly protected status.

List any additional information you would like us to consider

APPLICANT STATEMENT

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period of definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer’s service, whenever it is discovered.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Signature

Date

MonthDayYear