Online Application

Todays Date:
Last Name: First Name: Middle Initial:
Maiden Name or alias:
Telephone: Cell Phone:
Address:
City: State: Zip Code:


Employment Desired

Position applied for: Salary Desired:
How were you made aware of position?
Date you can start:      Full Time      Part Time      PRN
Are you 18 years of age or older?
Yes No 		           If not, do you have a work permit?
Yes No
Are you: Related to any current employees of this Agency? Related to a current Board member?
Yes       No

Name of employee or Board member:

Have you ever been convicted of a crime?
Yes      No

If yes, please describe:



Education

Name of School City, State Years Attended Type of Education Degree/Diploma
Y or N
High School
College/University
Other Education/Training
Professional License# State License#


Employment History

May we contact your present employer? Yes       No
Employer Name: Phone: Supervisor's Name:
Address: City: State: ZipCode:
Dates of Employment:From:To: Position:
Reason for leaving:

Employer Name: Phone: Supervisor's Name:
Address: City: State: ZipCode:
Dates of Employment:From:To: Position:
Reason for leaving:

Employer Name: Phone: Supervisor's Name:
Address: City: State: ZipCode:
Dates of Employment:From:To: Position:
Reason for leaving:


Professional References


Name: Phone:
Address: City: State: ZipCode:
Name: Phone:
Address: City: State: ZipCode:
Name: Phone:
Address: City: State: ZipCode:


STATE OF THE HEART HOSPICE
APPLICATION FOR EMPLOYMENT
NOTICE AND DISCLOSURE FORM


    I, , applicant for employment with Hospice of Darke County, Inc. dba State of the Heart Hospice (the Agency) do hereby grant the Agency permission to contact present and past employers (unless specified otherwise above) as well as those individuals I have listed as “References” for the purpose of verification of employment, and performance evaluations.

    I hereby grant the Agency permission to thoroughly:

  • Investigate any and all records pertaining to my present and past employment and personal references.

  • Request and verify any education institutes I have attended. (Example: high school, college, trade school, etc.)

  • Conduct a criminal background check or a limited background check.

  • Conduct an investigation concerning my driver’s license, place of residence, social security number and professional license.

    • I understand that employment is contingent upon information received during this process.

    I attest to the fact that any and all information supplied above is accurate and true to the best of my knowledge. I understand that falsifying information is grounds for disqualification of employment consideration or immediate dismissal from employment.

    Due to the nature of this business, staffing needs of the Agency vary, as do the duties of the position for which I have applied. It may be necessary for the Agency to change the shift/hours/duties of the position for which I have applied in order to meet Agency needs.

    Signature of Applicant: Date: