Hospice of Huntington Online Application

Employment Application

Step 1 of 6

References
List name, address and telephone number of two business or work references that are not previous supervisors. If not applicable, list two school or personal references that are not related to you.
Reference 1 Name*
First Last
Reference 1 Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Reference 1 Phone*
How many years have you known them?*
Reference 2 Name*
First Last
Reference 2 Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Reference 2 Phone*
How many years have you known them?*
Reference 3 Name
First Last
Reference 3 Address
Street Address City State / Province / Region ZIP / Postal Code Country
Reference 3 Phone
How many years have you known them?
List professional, trade, business, or civic associations and offices held that are applicable to this position. (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status.)
Organization Name
Offices Held
Organization Name
Offices Held
Organization Name
Offices Held
List special accomplishments, publications, awards (exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status).
List any additional information you would like us to consider.

PLEASE READ AND SIGN BELOW. IF THERE IS ANY PART OF THIS STATEMENT YOU DO NOT UNDERSTAND, PLEASE ASK THE HUMAN RESOURCE DIRECTOR OR THE INTERVIEWER ABOUT IT BEFORE SIGNING THIS STATEMENT.
I certify that I have not knowingly withheld any information that might affect my changes for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. It is understood and agreed upon that any misrepresentation by me on this application, or any documents used to secure employment, will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed regardless of the time elapsed before discovery. I authorize Hospice of Huntington, Inc. to thoroughly investigate my references, work records, education, driving records, criminal records and other matters related to my suitability for employment and, further, authorize my current and former employers to disclose to Hospice of Huntington, Inc. any and all letters, reports, and other information pertaining to my employment with them, without giving me prior notice or such disclosure. In addition, I hereby release Hospice of Huntington, Inc., my current and former employers, and all other persons, corporations, partnerships, associations, government agencies, and law enforcement agencies from any and all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure. I understand that nothing contained in the application or conveyed to me during my interview, which may be granted, is intended to create an employment contract, implied or explicit, between Hospice of Huntington, Inc. and me. In addition, I understand and agree that if I become employed, my employment relationship with Hospice of Huntington, Inc. is strictly voluntary and at our mutual will. I understand that if employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, with or without cause or reason, at the option of either Hospice of Huntington, Inc. or myself. I understand and agree that any future changes in my title, duties, compensation, working conditions, and/or benefits, policies and procedures will not alter our at-will agreement. I understand that if offered employment, I will, as a condition of employment, be required to submit proof of my identity and legal right to work in the United States on my first day of employment. I also agree to take and understand that an offer of employment is conditional on the satisfactory outcome of a criminal background, drug screen and reference check. I understand that I will be required to possess a current and valid driver’s license or submit proof of other means of transportation. I understand that I will be required to provide proof of insurance with state minimum in liability coverage, if offered employment. I understand Hospice of Huntington, Inc. is a drug-free workplace, and my employment is contingent upon submitting to, and a negative result on, a post-offer drug screen. Hospice of Huntington, Inc. is an Equal Opportunity Employers. The employer does not discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state or federal law. I understand it is Hospice of Huntington, Inc.’s policy not to refuse to hire a qualified individual with a disability because of this person’s need for an accommodation that would be required by the ADA. This application is current for one year. At the conclusion of this time, if I have not heard from Hospice of Huntington, Inc. and still wish to be considered for employment, it will be necessary to fill out a new application.*
I agree to the statement below
I certify that I have not knowingly withheld any information that might affect my changes for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. It is understood and agreed upon that any misrepresentation by me on this application, or any documents used to secure employment, will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed regardless of the time elapsed before discovery.

I authorize Hospice of Huntington, Inc. to thoroughly investigate my references, work records, education, driving records, criminal records and other matters related to my suitability for employment and, further, authorize my current and former employers to disclose to Hospice of Huntington, Inc. any and all letters, reports, and other information pertaining to my employment with them, without giving me prior notice or such disclosure. In addition, I hereby release Hospice of Huntington, Inc., my current and former employers, and all other persons, corporations, partnerships, associations, government agencies, and law enforcement agencies from any and all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure.

I understand that nothing contained in the application or conveyed to me during my interview, which may be granted, is intended to create an employment contract, implied or explicit, between Hospice of Huntington, Inc. and me. In addition, I understand and agree that if I become employed, my employment relationship with Hospice of Huntington, Inc. is strictly voluntary and at our mutual will. I understand that if employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, with or without cause or reason, at the option of either Hospice of Huntington, Inc. or myself. I understand and agree that any future changes in my title, duties, compensation, working conditions, and/or benefits, policies and procedures will not alter our at-will agreement.

I understand that if offered employment, I will, as a condition of employment, be required to submit proof of my identity and legal right to work in the United States on my first day of employment. I also agree to take and understand that an offer of employment is conditional on the satisfactory outcome of a criminal background, drug screen and reference check.

I understand that I will be required to possess a current and valid driver’s license or submit proof of other means of transportation. I understand that I will be required to provide proof of insurance with state minimum in liability coverage, if offered employment. I understand Hospice of Huntington, Inc. is a drug-free workplace, and my employment is contingent upon submitting to, and a negative result on, a post-offer drug screen.

Hospice of Huntington, Inc. is an Equal Opportunity Employers. The employer does not discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state or federal law. I understand it is Hospice of Huntington, Inc.’s policy not to refuse to hire a qualified individual with a disability because of this person’s need for an accommodation that would be required by the ADA.

This application is current for one year. At the conclusion of this time, if I have not heard from Hospice of Huntington, Inc. and still wish to be considered for employment, it will be necessary to fill out a new application.
Applicant's Digital Signature*
First Last
Date*
MM slash DD slash YYYY

Employment Application

Step 1 of 6

Employment History

Professional Licensure for Clinical Staff / CNA Certification

Educational Background

References

PLEASE READ AND SIGN BELOW. IF THERE IS ANY PART OF THIS STATEMENT YOU DO NOT UNDERSTAND, PLEASE ASK THE HUMAN RESOURCE DIRECTOR OR THE INTERVIEWER ABOUT IT BEFORE SIGNING THIS STATEMENT.