1.New Application 0315

Application for Employment
General Information
Please complete the application in its entirety. Incomplete applications will not be considered. You may attach supporting
documents such as your resume or cover letter. Resumes will not be accepted instead of a completed application.
Where did you hear about this position?
Friend / Relative
Newspaper
Walk-In
Heart of Hospice Website
Other: __________________________________
Employee Referral: _______________________________________________________
(Print Employee's Full Name and Position)
Personal Information
Name:
Date:
First
Middle
Last
List any other name(s) or alias:
Address:
Street
Home Phone:
Cell Phone:
-
City
State
-
Email:
-
Date Available to start work:
Position applied for:
Zip
Desired Wage: $
Please indicate your availability:
Full-Time
Per Diem (as needed)
Part-Time
If part-time or per diem, please list availability:
Are you able to perform the essential functions of the job for which you are applying with or w/out accommodation?
Are any friends or relatives employed by Heart of Hospice?
Y
N
Name, relationship?
Have you ever applied here before?
Y
N
If yes, approximate date:
Are you a citizen of the United States:
Y
N
If no, are you authorized to work in the U.S.? Y N
Have you ever been convicted of a felony?
Y
N
If yes, explain:
Important Information
Due to state/federal regulations along with Heart of Hospice’s dedication to providing our patients and employees with a safe and comfortable environment, all individuals offered employment at Heart of Hospice are required to successfully complete our preemployment process, which consists of a drug screening, criminal background check, and verification of education and employment history.
NOTE: Failure to fully disclose criminal offense record will render you INELIGIBLE for employment at Heart of Hospice. Conviction of a criminal offense will not necessarily disqualify you from employment, but the nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may be considered.
Education
Name and Location of High School:
Did you earn:
Diploma
GED
None
If none, please indicate highest grade completed:
Additional Education / Training
Name of Institution
Location
Course of Study
College, University, Trade, Military, etc.
City, State
Major/Minor
For LPN's ONLY: Have you completed IV Certification (30 hour course)?
Did you
Graduate?
Degree or Certificate
Received
No
Yes
Licensure, Certification, Registration
License, Certificate, or Registration
Number
Date Received
Expiration Date
State / Licensing Agency
License, Certificate, or Registration
Number
Date Received
Expiration Date
State / Licensing Agency
License, Certificate, or Registration
Number
Date Received
Expiration Date
State / Licensing Agency
Specialized Skills and Knowledge
List skills or knowledge that show your ability to perform the job for which you are applying (such as typing speed, computer
programs/knowledge, second language(s), etc.)
Experience
Please describe your work experience for the last 15 years beginning with your current or most recent job. Include a brief
explanation for any gaps in employment.
Name of Present or Last Employer:
Address:
Street
Phone #:
Suite #
City
Employed from:
Job Title:
/
To:
/
Duties & Responsibilities:
Supervisor's Name:
Email Address:
Reason for Leaving:
Compensation: Starting
May we contact for reference?
State
Yes / No
Ending
Zip
(month/year)
Name of Next Previous Employer:
Address:
Street
Phone #:
Suite #
City
Employed from:
Job Title:
/
State
To:
/
Zip
(month/year)
Duties & Responsibilities:
Supervisor's Name:
Email Address:
Reason for Leaving:
Compensation: Starting
May we contact for reference?
Ending
Yes / No
Name of Next Previous Employer:
Address:
Street
Phone #:
Suite #
City
Employed from:
Job Title:
/
State
To:
/
Zip
(month/year)
Duties & Responsibilities:
Supervisor's Name:
Email Address:
Reason for Leaving:
Compensation: Starting
May we contact for reference?
Ending
Yes / No
Name of Next Previous Employer:
Address:
Street
Phone #:
Suite #
City
Employed from:
Job Title:
/
To:
/
Duties & Responsibilities:
Supervisor's Name:
Email Address:
Reason for Leaving:
Compensation: Starting
May we contact for reference?
State
Yes / No
Ending
Zip
(month/year)
Professional References
Name
Occupation
Telephone / Email Address
Additional Comments and/or Skills
Heart of Hospice, LLC is an Equal Opportunity Employer
As a recipient of Federal financial assistance, Heart of Hospice, LLC does not exclude, deny benefits to, or otherwise discriminate against any
person on the ground of race, color, or national origin, or on the basis of disability or age in admission to, participation in, or receipt of the
services and benefits under any of its programs and activities, whether carried out by (insert name of provider) directly or through a contractor
or any other entity with which (insert name of provider) arranges to carry out its programs and activities.
This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the
Age Discrimination Act of 1975, and Regulations of the U.S. Department of Health and Human Services issued pursuant to these statutes at Title
45 Code of Federal Regulations Parts 80, 84, and 91. In case of questions, please contact: Jodi Goatcher, Heart of Hospice, LLC, at (541) 3861942.
Signature
I acknowledge that I have read this Application for Employment, including the Instructions for Completing the Application for Employment. I
acknowledge that I understood each and every question that was asked of me in the Application for Employment. I acknowledge that I was given
the opportunity by Heart of Hospice to ask questions regarding the Application for Employment and the hiring process. ________/Initial
I acknowledge that if Heart of Hospice employees me, I will be free to leave Heart of Hospice at any time for any reason and that Heart of
Hospice is free to separate my employment at any time and for any reason without prior notice. I understand that this is called “employment at
will,” and no one other than an officer of Heart of Hospice has the authority to alter this arrangement, to enter into an agreement for
employment for a specified period of time, and/or to make any agreement contrary to the at-will nature of my employment. Furthermore, I
understand that any such agreement that is contrary to the at-will nature of my employment must be in writing signed by an officer of Heart of
Hospice. _______/Initial
I acknowledge and understand that if I am offered a position by Heart of Hospice, the job offer is contingent on my satisfactorily completion of a
drug screen analysis, background investigation, proof of my legal identification, and authorization to work in the United States. ________/Initial
I acknowledge and affirm that the answers I have provided in this Application for Employment are true and accurate. I further acknowledge that
I have not withheld any information that was requested of me in this Application for Employment. I also understand that all statements made by
me in connection with my application for employment are true and correct and may be checked by Heart of Hospice. I authorize Heart of
Hospice to contact my prior employers, including each of those employers listed above, and other sources information regarding my
background. I hereby authorize and direct each such employer and source of information to answer any and all questions regarding my prior
employment and background. I hereby agree to indemnify Heart of Hospice and further agree to hold it harmless from any claims arising from
this authorization and direction. I understand and acknowledge that any misrepresentations, false statements, and/or omissions made by me in
completing this Application for Employment may result in my not being considered for employment by Heart of Hospice and/or may lead to
disciplinary action, up to and including the separation of my employment if discovered by Heart of Hospice after I have been hired.
_______/Initial
Signature
Date