Employment Application

Hospice of the North Coast prohibits discrimination and harassment of any type and affords equal employment opportunities to employees and applicants without regard to race, color, religion, sex, age, national origin, disability status, protected veteran status, or any other characteristic protected by law.

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

State name and relationship to any relatives employed by Hospice of the North Coast

Referred by

Desired Position *

Date you can Start *

Desired Salary (per year) *

Education

High School Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Graduated?

Yes
No

College Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Degree Received

Other Schooling Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Degree Received

Employment History

Are you currently employed?

May we contact your current employer?

Employer Name 1

Former
Current

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Employed from

Employed to

Position

Reason for leaving

Employer Name 2

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Employed from

Employed to

Position

Reason for leaving

Employer Name 3

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Employed From

Employed to

Position

Reason for leaving

Professional References

Please provide three professional references. (One must be a Supervisor) Include their full name, an email address, relationship, and a contact number.

Reference #1 Name

Email

Relationship

Phone

Reference #2 Name

Email

Relationship

Phone

Reference #3 Name

Email

Relationship

Phone

Additional Information

If you hold a license or certification for nursing or other professional services, has it ever been revoked for any reason?

Authorization

Please Read Carefully, Initial each Paragraph and Electronically Sign Below.

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. *

I hereby authorize to thoroughly investigate my references, work record, education and other matters related to my suitability for employment (excluding criminal background information) unless otherwise specified above. I further authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure. *

I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Company's designated representative. *

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire. The Company will consider qualified applicants, including those with criminal histories, in a manner consistent with state and local "Fair Chance" laws. *

Hospice of the North Coast prohibits discrimination and harassment of any type and affords equal employment opportunities to employees and applicants without regard to race, color, religion, sex, age, national origin, disability status, protected veteran status, or any other characteristic protected by law.

Electronic Signature *

First

Last

I agree, by typing my First and Last name that Hospice of the North Coast may use this as my electronic signature.

Application Date *

Employment Application