Employment Application Position(s) Applied For*Name* First Middle Initial Last Address* Address (present) Number Street City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Best time to contact you at home is*Have you ever been employed with us before?*YesNoIf yes, give date* Date Format: MM slash DD slash YYYY May we contact your present employer?YesNoDate available to work* Date Format: MM slash DD slash YYYY Are you available to work Mornings Afternoon Evenings Nights Weekends Holidays Per Diem On-Call Hours per week you are willing to workDo you have your own transportation?*YesNoHave you ever been excluded or been determined ineligible for participation in Medicare or Medical Assistance?*YesNoIf yes, please explain*Have you ever been convicted of any criminal activity?*YesNoIf yes, please explain*Prior to employment and every four years thereafter, employees must complete a State of Wisconsin Department of Health and Family Services Background check, under the provisions of section 48.685 and 50.065 of the Wisconsin statutes. Failure to comply will result in termination of employment.Describe any specialized training, apprenticeship, skills and extra-curricular activities.Registration / Certification / LicenseTypeNumberStateExpirationAdditional InformationOther Qualifications Summarize special job-related skills and qualifications acquired from employment or other experience.Personal/Professional ReferencesDo not include family members or past supervisors.Reference #1Name*Phone Number*Occupation*Reference #2Name*Phone Number*Occupation*Reference #3Name*Phone Number*Occupation*Why do you want to work with Hospice?Applicant's StatementI certify that the information contained in this application is true and complete. I understand that any falsification or omissions of information will be sufficient grounds for denial of employment, and if hired, for termination. I understand that employment is conditioned upon verification of the information contained herein. I authorize the listed employers, schools, and personal references, as well as any other persons; schools; companies; credit bureaus; state licensing; law enforcement and other government agencies; to give Hope Hospice and Palliative Care, Inc. (without further notice to me) any and all information about my previous employment and education, along with any other pertinent information they may have, personal or otherwise. I release all parties from all liability, and agree not to file any claim, lawsuit of any other cause of action of any kind against any person or entity arising out of the furnishing or use of such information. I understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with Hope Hospice and Palliative Care, Inc. is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct. In consideration of my employment by Hope Hospice and Palliative Care, Inc. I agree to learn and conform to Hope Hospice and Palliative Care, Inc. rules and policies. I further agree that I have the right to terminate my employment without notice at any time for any reason, and that Hope Hospice and Palliative Care, Inc. also retains this right.* I accept Applicant's Statement NondiscriminationIt is the policy of Hope Hospice and Palliative Care, Inc., to consider all applicants for employment without regard to age, race, religion, creed, color, handicap (disability), marital status, sex, national origin, ancestry, sexual orientation, military status or any other legally protected status. No questions on this application are intended to secure information to be used for such discrimination.