TO APPLICANT: READ THIS INTRODUCTION CAREFULLY BEFORE ANSWERING ANY QUESTIONS.

The Civil Rights Act of 1964 prohibits discrimination in employment practice because of race, color, creed, sex, national origin, handicap, marital status, or arrest records. P.L. 90-202 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.

We deeply appreciate your interest in Hospice and assure you that we are sincerely interested in your qualifications. A clear understanding of your background an work history will aid us in placing you in the position best meeting your qualifications and may assist you in possible future upgrading.
Position(s) applied for:
Expected rate of pay $:
Would you work full time? Yes  No
Would you work part time? Yes  No
Please specify days, hours, and shift (if applicable):
Were you previously employed by us? Yes  No
If yes, when?
Is any additional information relative to a change in name, use of an assumed name or nickname necessary to enable a check on your work record? Yes  No
If yes, explain:
Personal
First Name: Middle Initial:
Last Name:
Social Security #:
Present Address:
Town/City: State:
Zip Code:
Telephone:
Other number where you may be reached:
Are you 18 or older? Yes  No
Have you ever been convicted of a crime? Yes  No
If yes, describe in full:

Do you have any impairments, physical , mental, or medical which would interfere with your ability to perform the job for which you have applied?
Yes  No
If yes, describe:
Education
Select last year completed:
Elementary School:
High School:
College:
Describe Training or Education:
References
List below last three employers, starting with last one first:
 
Date: mm/yy Name/Address/Phone # of Employer Supervisor Salary Position Reason for Leaving
From:
To:
           
From:
To:
           
From:
To:
List the names of three professional references not related to you whom you have known at least one year:
Name Professional Relationship Address (include zip) Telephone
May we contact present and past employers and references? Yes  No
If not, indicate which one you do not wish us to contact and why:
I understand and agree that:
  1. Any material misrepresentation or deliberate omission of a fact in my application may be justification for refusal of, or if already employed, termination from employment.
  2. Hospice will make a thorough investigation of my entire work history and may verify all data given in my application for employment, related papers, or oral interviews. I authorize such investigation and the giving and receiving of any information requested by Hospice and I release from liability any person giving or receiving any such information. I understand that falsification of investigation may prevent my being hired, or if hired, may subject me to immediate dismissal.
  3. I authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the duties of a job I am being considered for prior to employment or in the future during my employment with Hospice. I consent to take a medical examination by a qualified physician at the discretion of my employer.
I have read and understand the above:
Print your name: