Hospice application

We are an equal opportunity employer and do not discriminate on the basis of race, religion, color, national origin, age, sex, gender, disability or any other characteristic protected by law.

INTRODUCTORY INFORMATION:

Name*

First NameMiddle NameLast Name

Application date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Area CodePhone Number

E-mail*

APPLICANT QUESTIONS:

Type of work desired:*

Wage or salary desired:*

How many hours per week would you like to work?*

YesNo

Less than one yearOne to two yearsMore than two yearsUncertain

How did you hear about us? If referred, please provide referrer's name.

YesNo

If yes, please explain in detail and include the date of final disposition of the case and the nature of the offense. This information will not necessarily disqualify you from employment but false or misleading information will. Factors such as age and time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account.

College, Professional or Technical School:

Course of Study:

Number of Years Completed:

Degree/Diploma earned and year:

College, Professional or Technical School (second):

Course of Study:

Number of Years Completed:

Degree/Diploma earned and year:

Military Experience:

Branch of Service:

From:

To:

Rank/Type of Service:

Special Training/Experience:

Record of Employment:

List positions starting with most recent:

Most recent employer:

Telephone:

Address:

Position Title:

Supervisor:

Start Date:

Date Left:

Beginning Salary:

Ending Salary:

Duties:

Reason for Leaving:

YesNo

Previous employer:

Telephone:

Address:

Position Title:

Supervisor:

Start Date:

Date Left:

Beginning Salary:

Ending Salary:

Duties:

Reason for Leaving:

YesNo

Previous employer:

Telephone:

Address:

Position Title:

Supervisor:

Start Date:

Date Left:

Beginning Salary:

Ending Salary:

Duties:

Reason for Leaving:

YesNo

Work-Related References: (Do not include relatives)

Reference 1

Name

Occupation

Years Known

Contact Information

Reference 2

Name

Occupation

Years Known

Contact Information

Reference 3

Name

Occupation

Years Known

Contact Information

Your Availability for Work:

Please provide your anticipated availability or limitations for each day of the week below.

Monday*

From - To

Tuesday*

From - To

Wednesday*

From - To

Thursday*

From - To

Friday*

From - To

Saturday*

From - To

Sunday*

From - To

Do you have any special requests or needs for a work schedule, or any other comments about your availability?

Resume or CV

Browse Files

STATEMENT (Please read this statement carefully before signing this application):
I will authorize the Company to conduct a thorough background investigation of my work and personal history, and verify all data given on this application and during interviews. I hereby release the Company, and its representatives or agents, from any liability that might result from such an investigation. I authorize all individuals, schools, and firms named to provide any requested information and release them from all liability for providing the requested information.
I understand that the Company may require the successful completion of a drug and/or alcohol test as a condition of employment.
I understand this application will be active for a period of 90 days; after that time, if I wish to be considered for employment, I must submit a new application. I certify that all the statements in this completed application are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal to hire.

Signature

Application for Employment