Hospice Services | Owensboro, KY

Application for Employment

First Name:

Middle Name:

Last Name:

Address:

City:

State:

Zip Code:

Phone Number:

Email Address:

How did you learn about this position?

If referred by employee, type their name below:

Please provide all names used at work for employment verification:

Position(s) applied for (in order of choice):

Date available for employment:

Applying for (check all that apply):

Full-Time

Part-Time

PRN

Other

Shift Preference:

Have you graduated from high school?

Are you at least 18?

If no, are you at least 16?

College/University/Nursing School/Vocational School History (include location):

Course Study - Degree: Major and Field

Graduated

Graduation Date

If no, projected date?

Professional licenses or certificates:

Are you presently employed?

If yes, may we contact your current employer?

If no, please explain:

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Provide a complete work history:

Company Name:

Phone:

Address:

Employed From (Month & Year):

Employed To (Month & Year):

Name and Title of Supervisor:

Position Held:

Reason for Leaving:

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Company Name:

Phone:

Address:

Employed From (Month & Year)

Employed To (Month & Year)

Name and Title of Supervisor:

Position Held:

Reason for Leaving:

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Company Name:

Phone:

Employed From (Month & Year)

Employed To (Month & Year)

Address:

Name and Title of Supervisor:

Position Held:

Reason for Leaving:

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References:

Name:

Title/Organization:

Relationship to Applicant:

Phone:

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Name:

Title/Organization:

Relationship to Applicant:

Phone:

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Have you ever been discharged from a job?

If yes, list employer, dates, reason, and explanation:

A conviction record will not necessarily disqualify an applicant from employment. The circumstances of a conviction will be considered in relation to the nature and duties of the job for which you apply. Do you have a record of founded child or dependent adult abuse, or have you ever been convicted of a crime, in this state or any other?

If yes, please explain:

Citizenship Within three days after employment, you will be required by IRCA guidelines to prove your citizenship or eligibility as an alien. Are you a citizen of the United States or specifically authorized to be employed in the United States?

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By signing below, I certify that the answers and information set out above are true, accurate, and complete to the best of my knowledge. I acknowledge that if any answer or information is not true, accurate, or complete, I may not be hired: or if hired, I may be discharged.

I authorize the employer to investigate all statements contained in this application for employment to include criminal, child and dependent adult abuse information as well as my character and qualifications. I release the employer from all liability for acts performed in good faith and without malice in connection with evaluation of my application.

I authorize my prior employers, references, and others with information regarding my work, educational history, or my character, to provide the employer with all information requested and to cooperate fully with the investigation of my character and qualifications. I also release those employers, referenced and others from all liability for providing information in good faith and without malice.

I understand this application is not a contract of employment. If hired, my employment and compensation can be terminated at will, with or without a showing of cause, and with or without notice by either me or my employer. I agree that if employed, I will abide by all policies, procedures, rules and regulations established by Hospice of Western Kentucky. (If completing electronically, you will be asked to sign in the space below at time of interview.)

Name:

Date:

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HPC – Hospice and Palliative Care of Western Kentucky does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, sexual orientation, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used or such discrimination.