Job Application - Hope Hospice and Palliative Care

Position(s) Applied For*

Name*

First Middle Initial Last

Address*

Street Address City State Zip Code

Phone

Email

Best time to contact you at home is*

Have you ever been employed with us before?*

Yes
No

If yes, give date*

May we contact your present employer?

Yes
No

Date available to work*

Are you available to work

Mornings
Afternoon
Evenings
Nights
Weekends
Holidays
Per Diem
On-Call

Hours per week you are willing to work

What is your current wage?

Do you have your own transportation?*

Yes
No

Have you ever been excluded or been determined ineligible for participation in Medicare or Medical Assistance?*

Yes
No

If yes, please explain*

Have you ever been convicted of any criminal activity?*

Yes
No

If 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.

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Registration / Certification / License

Type

Number

State

Expiration

Additional Information

Other Qualifications Summarize special job-related skills and qualifications acquired from employment or other experience.

Personal/Professional References

Do not include family members or past supervisors.

Reference #1

Name*

Phone Number*

Occupation*

Reference #2

Name*

Phone Number*

Occupation*

Reference #3

Name*

Phone Number*

Occupation*

Why do you want to work with Hospice?

Applicant's Statement

I 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

Nondiscrimination

It 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.

Employment Application

Registration / Certification / License

Reference #1

Reference #2

Reference #3

Applicant's Statement

Nondiscrimination