Creekside Hospice

EMPLOYMENT APPLICATION

Creekside Hospice
Application For Employment

Creekside Hospice is an equal opportunity employer. Creekside Hospice does not discriminate in hiring on the basis of race, religion, national origin, color, gender, age or disability so long as the perspective employee has the ability to perform the essential functions of the job.

PERSONAL INFORMATION

Date // Social Security Number --

Name
	Last	First	Middle

Present Address	,
	Street Name	City	State	Zip
Permanent Address	,
	Street Name	City	State	Zip

Home Phone Number -- or --

EMPLOYMENT INFORMATION

Position Applying For
Are you licensed and/or certified as (please check applicable areas)

Registered Nurse (RN)	Licensed Practical Nurse (LPN)	Nurses Aide (NA)
Home Health Aide (HHA)	Physical Therapist (PT)	Occupational Therapist (OT)
Speech Therapist (ST)	Social Worker (MSW/CSW)	Other

Yes No
State(s) you are currently licensed in:

Have you applied to Creekside Hospice prior to today’s date? No / Yes
If Yes, When? //

EDUCATION

Last Grade Completed:

	Name of School	Location	Did You Graduate?	Degree Earned
High School			Yes No
College			Yes No
Trade / Business			Yes No
Other			Yes No

FORMER EMPLOYERS

List below the last three employers, most recent first.

DATES:	Company Name / Address:	Phone Number:
From:
To:		Supervisor's Name:

Salary:	Positions / Duties Performed:	Reason For Leaving:

DATES:	Company Name / Address:	Phone Number:
From:
To:		Supervisor's Name:

Salary:	Positions / Duties Performed:	Reason For Leaving:

DATES:	Company Name / Address:	Phone Number:
From:
To:		Supervisor's Name:

Salary:	Positions / Duties Performed:	Reason For Leaving:

Have you ever been involuntarily terminated or have you ever resigned rather than face involuntary termination from any job?
Yes No
If so, please indicate the reason.

Have you ever been cited for any traffic violations, other than parking, in the last 3 years?
Yes No
If so, please indicate the reason.

May we contact your current employer?
Yes No
If no, please indicate the reason.

HOURS AVAILABLE TO WORK

Days	Saturday	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday
From
To

Are you available to work weekends? Yes No
Are you available to work holidays? Yes No

REFERENCES

Please list 3 non-family References (name, address and phone)
1.
2.
3.

Please Read Carefully Before Signing:

I certify that the information is correct and that the falsification of this information shall be grounds for dismissal if Creekside Hospice employs me. I understand that the employment may be terminated, with or without cause at any time, with or without notice at the option of Creekside Hospice. I further understand that Creekside Hospice may, from time to time, promulgate employment policies and procedures or other information, whether written or otherwise, shall constitute an employment contract, either expressed or implied. If I am employed with Creekside Hospice, I fully understand that no manager or other representatives of Creekside Hospice, other than the president or vice president, shall have any authority to enter into any contract for employment or any other agreement contrary to the foregoing.

Applicant’s Signature

Date

Creekside HospiceApplication For Employment

Please Read Carefully Before Signing:

Creekside Hospice
Application For Employment