Application

Position*
Position
Date of Application:
Date Format: MM slash DD slash YYYY
How did you learn of this vacancy?
FIRST NAME LAST NAME Middle Initial
Present Street Address City
State/Country:
Zip
Phone
Best time to call:
: HH
MM
Work Phone:
Email Address:
Cell Phone #:
List all places where you have lived during the past 10 years:
Address City State Zip From (mo/yr) To (mo/yr)
Employment Record
Please complete starting with present or most recent employer. Include summer employment and military experience;indicate honorable or dishonorable discharge. For any unemployed or self-employed periods, show dates and locations.Provide all information requested on application. Resumes CANNOT be used in place of completing this section. All ofemployer related information requested must be furnished for the last TEN (10) years including gaps in employment. Ifyou need additional space, please use an Employment Record Supplemental form.
Present Employer (if currently employed)
Job Title:
Address:
Reason for Leaving:
City / State:
Phone
From:
To:
Supervisors name:
Number of employees you supervised:
Duties:
Salary:
Present Employer
Job Title:
Address:
Reason for Leaving:
City / State:
Phone
From:
To:
Supervisors name:
Number of employees you supervised:
Duties:
Salary:
Present Employer
Job Title:
Address:
Reason for Leaving:
City / State:
Phone
From:
To:
Supervisors name:
Number of employees you supervised:
Duties:
Salary:
Present Employer
Job Title:
Address:
Reason for Leaving:
City / State:
Phone
From:
To:
Supervisors name:
Number of employees you supervised:
Duties:
Salary:
Do you have objection to your past or present employer(s) being contacted?*
- Yes
- No
If yes, indicated which employer(s) and why:
Education And Training
G.E.D. Certificate
- Yes
- No
Name and Address Last High School Attended
High School Diploma
- Yes
- No
Highest Grade Completed:
College Attended No. of Years Major Type of Degree Recieved
Vocational/Training, Trade Business, Armed Forces
School (s) attended Length of Program Program Type of Certificate Received
Clerical Skills: Typing :
wpm:
Shorthand :
wpm:
Legal Information
1. Have you ever been convicted of a crime, entered a plea of nolo contendere (no contest) to a crime, had a adjudication,withheld or received a suspended sentence (regardless of the ultimate adjudication) for a crime?
- Yes
- No
Charge:
Date
Date Format: MM slash DD slash YYYY
Disposition:
Sentence:
2. Are you now on probation?
- Yes
- No
Probationary period: From:
Date Format: MM slash DD slash YYYY
To:
Date Format: MM slash DD slash YYYY
3. Have you ever been convicted of domestic violence, or injury to any person of damage to any property, i.e., for assault,battery, etc.?
- Yes
- No
if yes, date(s):
Please explain in the nature of the claims in the lawsuit(s)
4. Has any board, bureau, department, agency or other public body, in any way limited, restricted, suspended, or revokedany professional license or certificate granted to you; place you on probation; imposed a fine; censure or reprimand againstyou?
- Yes
- No
Statement Of Understanding And Release Of Information
1. This employer is an EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER and maintains a drug-freeworkplace. We do not discriminate on the basis of race, color, religion, sex, national origin, age, sexual orientation,disability, marital status, citizenship or veteran status.

2. Your application will not be considered unless complete answers are provided to all questions on this application.Resumes may be submitted as supplements, but cannot be accepted in lieu of this application.

3. A material omission in, orfalsification of, this application, your resume, or any other information provided by you at anytime may be grounds for not employing you or dismissal after you begin work.

4. Nothing in this application or in the policies, rules, or regulations is intended to create a contractual relationship betweenthe Company and any employee. The Company reserves the right to change its policies at any time. You will berequired to adhere to all policies.

5. Federal law (Immigration Reform and Control Act of 1986) prohibits the employment of authorized aliens. All personshired must submit satisfactory proof of employment eligibility and identity. Any offer of employment is contingent onyour submission of satisfactory proof of your identity and your legal authorization to work in the United States. If youfail to submit this proof, federal law prohibits us from hiring you. In the event you have begun to work and are unable tosubmit this required information in a timely manner, your employment will be terminated.

6. Offers of employment are contingent upon successful completion of a medical questionnaire and/or a physicalexamination to determine your ability to meet the state and/or federal employment requirements and to perform theessential functions of the job you are seeking.

7. I CONSENT freely and voluntarily to any request for specimens for the purpose of drug testing and the release of theresults of the specimen analysis. I agree to voluntarily participate in any pre-employment, reasonable suspicion, andpost-accident testing program. I understand that in the event I refuse to be tested, refuse to execute Consent or testpositive, I will be disqualified from further employment consideration or terminated.

8. To assist the Company in assessing my qualifications for the position for which I am applying, I hereby authorize thesearch regarding my present and previous employment, licenses, certifications, educational records, references, and anyother information provided (except where otherwise indicated). I herebyrelease the Company and any person whoprovides such information from any liability or damage, which may result from furnishing requested information.

9. I hereby understand that I am notified that State Statues require any individual employed or seeking employment in ahospice meet the requirements set forth regarding criminal history compliance and good moral character and holdthe Company harmless for its interpretation of eligibility for employment based on or criminal history.

10. I hereby to consent to and authorize the information requested within this form and agree to hold harmless the companyand any persons from any liability in furnishing this reference of employment
Application Signature
Date
Date Format: MM slash DD slash YYYY

Address	City	State	Zip	From (mo/yr)	To (mo/yr)

College Attended	No. of Years	Major	Type of Degree Recieved

School (s) attended	Length of Program	Program	Type of Certificate Received

Application

Employment Record

Education And Training

Vocational/Training, Trade Business, Armed Forces

Legal Information

Statement Of Understanding And Release Of Information