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304.529.4217 or toll-free 800.788.5480


General Information
First Name:
Middle Name:
Last Name:

Present Address
Address:
City:
State:
Zip Code:
How long at current address?
Telephone:
E-Mail:

Are you under age 18?
Yes No
Are you currently authorized to work in the United States?
Yes No
*Proof of eligibility will be required if hired*
Position applied for:
Wage desired:

How many hours can you work weekly?

Employment desired:
When are you available to start work?
Days/hours available to work
Monday:
Tuesday:
Wednesday
Thursday:
Friday:
Saturday:
Sunday:
No Preference:

I am interested in:




School Experience
High School
Type of School:
Name of School:
Location:
# Years Completed:
Diploma: Yes No
Type of School:
Name of School:
Location:
# Years Completed:
Diploma: Yes No

*Must fill out at least one section*
College
Name of School:
Location:
# Years Completed:
Major & Degree:
Name of School:
Location:
# Years Completed:
Major & Degree:

Bus. or Trade School
Name of School:
Location:
# Years Completed:
Major & Degree:
Name of School:
Location:
# Years Completed:
Major & Degree:

Professional School
Name of School:
Location:
# Years Completed:
Major & Degree:
Name of School:
Location:
# Years Completed:
Major & Degree:

Employment Background
Have you pled guilty or no contest to or been convicted of any crime? Yes No
Driver’s License
Driver’s License?
Yes No
Driver’s license number:
State of issue:
Expiration date:
Means of Transportation to work?
Any accidents during the past three years?
Yes No
Any moving violations during the past three years?
Yes No
Any chargeable accidents during the last three years?
Yes No
Have you had any major convictions (driving under the influence, reckless driving, etc?) or license suspension or revocations within the past seven years?
Yes No
Office Skills
Microsoft ® Office Products: Word Excel PowerPoint Publisher Outlook
PC: Yes No
MAC: Yes No

References
Name:
Position:
Company:
Address:
Telephone:
Name:
Position:
Company:
Address:
Telephone:

*Please list two references other than relatives.*
Experience
Please use this space to elaborate on any background, experience, or qualifications that you believe should be considered in evaluating your qualifications for employment. You may include hobbies, volunteer experience and any other activities you believe relevant. Please omit any information that would disclose your race, gender, age, marital status, ethnic origin, religious or political affiliations, or disability.
Work Experience
Please list your work experience for the past seven years beginning with your most recent job held. If you were self-employed, give firm name.


General Info
Name of Employer:
Address:
City:
State:
Zip:
Phone Number:
Employment Dates
From:
To:
Pay or Salary
Start:
Final:
Name known by at work:
Your last job title:
Reason for leaving:


List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

General Info
Name of Employer:
Address:
City:
State:
Zip:
Phone Number:
Employment Dates
From:
To:
Pay or Salary
Start:
Final:
Name known by at work:
Your last job title:
Reason for leaving:


List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

General Info
Name of Employer:
Address:
City:
State:
Zip:
Phone Number:
Employment Dates
From:
To:
Pay or Salary
Start:
Final:
Name known by at work:
Your last job title:
Reason for leaving:


List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

General Info
Name of Employer:
Address:
City:
State:
Zip:
Phone Number:
Employment Dates
From:
To:
Pay or Salary
Start:
Final:
Name known by at work:
Your last job title:
Reason for leaving:


List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

May we contact your present employer? Yes No
Please indicate if you are able to perform the essential functions of the job for which you have applied
Yes No
Resume Submission
Resume:
File types: .doc, .docx, and .pdf
PLEASE READ CAREFULLY

APPLICATION FORM WAIVER

As indication that you have read and understood each sentence, please write your initials in the spaces provided below.

In exchange for the consideration of my job application by Hospice of Huntington, Inc. (hereinafter called "Hospice"), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements and the like as they may exist from time to time, or other Hospice practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee with Hospice, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Executive Director of Hospice. Both the undersigned and Hospice may end the employment relationship at any time, without specified notice or reason. If employed, I understand that Hospice may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Hospice or their representative permission to contact schools, all previous employers (unless otherwise indicated), references and others and hereby release Hospice from any liability as a result of such contact.

I understand that, in connection with the routine processing of your employment application, Hospice may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, and personal characteristics. In addition, Hospice may require pre-employment drug screening. Upon written request from me, Hospice will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I understand that upon an offer of employment, I will be required to sign an additional employment inquiry release authorizing an independent company to perform a background check on behalf of Hospice of Huntington. I further understand that the offer of employment is contingent upon the completion of a satisfactory background check.

Signature of applicant:

Hospice is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, gender, sexual orientation, national origin, citizenship, age or disability.

Thank you for completing this application form and for your interest in Hospice of Huntington, Inc...