Employment Application

Last Name

First

Middle

Address

City

State

Zip

Preferred Phone Number

Type of phone Type of phone Home Phone Cell Phone

Alternate Phone Number

Type of phone Type of phone Home Phone Cell Phone

Email Address

Are you 18 years old or older? Are you 18 years old or older? Yes No

Age

Are you legally eligible for employment within the United States? Are you legally eligible for employment within the United States? Yes No

Have you ever been convicted of a felony? Have you ever been convicted of a felony? Yes No

If yes, explain

Do you have any relatives employed by Faith Hospice? Do you have any relatives employed by Faith Hospice? No Yes

If yes, who?

Have you ever been employed by Faith Hospice? Have you ever been employed by Faith Hospice? Yes No

If yes, when?

How were you referred to us?

Position Applying For

Salary Desired

Are you applying for Are you applying for Full Time Part Time Temporary

Date Available for Work

Would you consider working Would you consider working Full time Part time Temporary

High school attended/address

High school course of study

Last year of high school completed

Did you graduate? Did you graduate? Yes No

College attended/Address

College course of study

List diploma, degree, or #hours

Last year of college completed

Did you graduate? Did you graduate? Yes No

College attended/Address

College course of study

List diploma, degree, or #hours

Last year of college completed

Did you graduate? Did you graduate? Yes No

Special courses, military training, post grad, etc.

Area of specialization or special interest

Are you currently Are you currently Registered Licensed Certified

Are you eligible for Are you eligible for Registration Licensure Certification

License or Certification type 1

State issued

Date

Expiration Date

License or Certification Number

License or Certification type 2

State issued

Date

Expiration Date

License or Certification Number

License or Certification type 3

State issued

Date

Expiration Date

License or Certification Number

Employed From (Most Recent)

Employed To (Most Recent)

Last Salary

Reason for leaving

Job Title

Duties/Responsibilities

Employer Name

Immediate Supervisor

Telephone Number

Address

City/State

Zip Code

Employed From

Employed To

Last Salary

Reason for leaving

Job Title

Duties/Responsibilities

Employer Name

Immediate Supervisor

Telephone Number

Address

City/State

Zip Code

Employed From

Employed To

Last Salary

Reason for leaving

Job Title

Duties/Responsibilities

Employer Name

Immediate Supervisor

Telephone Number

Address

City/State

Zip Code

Employed From

Employed To

Last Salary

Reason for leaving

Job Title

Duties/Responsibilites

Employer Name

Immediate Supervisor

Telephone Number

Address

City/State

Zip Code

Branch of Military Service

Served from

Served to

Branch at discharge

Type of discharge

If other than honorable, please explain

Professional Reference Name/Title

Company Name/Address

Phone

Professional Reference Name/Title

Company Name/Address

Phone

Professional Reference Name/Title

Company Name/Address

Phone

TERMS OF AGREEMENT: I certify that the information contained in this application is true and correct to the best of my knowledge and agree to have any of the statements checked by Faith Hospice unless I have indicated to the contrary. I authorize the references listed above to provide Faith Hospice any and all information concerning my previous employment and pertinent information that they may have. Further, I release all parties and persons from any and all liability of all damages that may result from furnishing such information to Faith Hospice or any of its agents, employees or representatives. I understand that any misrepresentation, falsification or material omission of information on this application may result in failure to receive an offer, of if am hired, in my dismissal from employment. In consideration of my employment, I agree to confirm to the rules and standards of the company and agree to my employment and compensation can be terminated at will, with or without cause, and with or without notice at any time, either at my option or at the option of the company. TERMS OF AGREEMENT: I certify that the information contained in this application is true and correct to the best of my knowledge and agree to have any of the statements checked by Faith Hospice unless I have indicated to the contrary. I authorize the references listed above to provide Faith Hospice any and all information concerning my previous employment and pertinent information that they may have. Further, I release all parties and persons from any and all liability of all damages that may result from furnishing such information to Faith Hospice or any of its agents, employees or representatives. I understand that any misrepresentation, falsification or material omission of information on this application may result in failure to receive an offer, of if am hired, in my dismissal from employment. In consideration of my employment, I agree to confirm to the rules and standards of the company and agree to my employment and compensation can be terminated at will, with or without cause, and with or without notice at any time, either at my option or at the option of the company. I agree to the terms of agreement