Hospice Employment Application

Position Applied For:

Job Code:

Date:

Name: First /Last / MI (required)

Street:

Apt#:

City:

State:

Zip:

Home Phone:

Email: (required)

Social Security Number:

AVAILABILITY

Date available to work

I am available for: (check all that apply)

Full TimePart TimePer Diem

(Or specifically)I am available for: (check all that apply)

EveningsDaysNightsWeekendsFlexible

What is your desired salary range?

REFERRALS

Please provide the names of at least three references (not friends, relatives or co-workers)that may be contacted by us. All references should have a specific knowledge of your work experience and have supervised your performance.

REFERRAL SOURCE #1

Referral Name:

Referral Phone:

How does this person know you?:

REFERRAL SOURCE #2

Referral Name:

Referral Phone:

How does this person know you?:

REFERRAL SOURCE #3

Referral Name:

Referral Phone:

How does this person know you?:

EMPLOYMENT

Are you currently employed?

YesNo

If yes, may we contact your current employer?

YesNo

(Please provide information concerning your current or past employer)

Employer:

Address:

Phone Number:

Job Title:

Supervisor:

Dates Employed:

Job Duties:

Are you authorized to work in the United States?:

(Proof of authorization will be required)
YesNo

Have you ever been employed by Avalon Hospice & Palliative Care before?

YesNo

If yes, give date:

Do you drive?:

YesNo

Do you have a car you can use for volunteer work?

YesNo

Do you have a valid driver’s license?

YesNo

Driver’s license number:

Have you had your Driver’s license suspended/revoked in the last 3 years?:

YesNo

Have you ever been convicted of a felony?:

YesNo

If yes, please explain the conviction.
(A conviction will not necessarily disqualify you from employment.):

EDUCATION

High School

School Name and Location:

Years Completed Diploma/Degree:

9101112

Diploma/Degree:

Undergraduate College / University

School Name and Location:

Years Completed Diploma/Degree:

1234

Diploma/Degree:

Graduate/Professional

School Name and Location:

Years Completed Diploma/Degree:

1234

Diploma/Degree:

LIST PROFESSIONAL LICENSES, CERTIFICATIONS OR REGISTRATIONS

#1

TYPE:

STATE:

NUMBER:

EXPIRATION DATE:

#2

TYPE:

STATE:

NUMBER:

EXPIRATION DATE:

#3

TYPE:

STATE:

NUMBER:

EXPIRATION DATE:

State any additional information you feel may be helpful to us in considering your application:

APPLICANT STATEMENT

I certify that the information contained in this application is correct to the best of my knowledge and understand that falsification or omission of pertinent information is grounds for refusal to hire, or if hired, dismissal. I understand that any offer of employment is contingent upon satisfactory proof of identity and legal authority to work in the U.S. I understand that any offer of employment is contingent upon successful completion of a health assessment and TB test. Any candidate who refuses to go through the health assessment including the TB test will not be considered for employment with Avalon Hospice & Palliative Care.

I authorize any of the persons or organizations referenced in this application to give you any and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application. I hereby release them and Avalon Hospice & Palliative Care from any and all liability for issuing, receiving, or using any such information. I authorize Avalon Hospice & Palliative Care to request and receive such information.

In consideration for my employment by your company, I agree to conform to the rules and regulations of the company and acknowledge that these rules and regulations may be changed, interpreted, withdrawn, or added to at any time, at the company’s sole option and without prior notice to me, provided however the “at will” status of the employment described below cannot be modified. Any employment resulting from this application process will be “at will”. I acknowledge that my employment may be terminated and any offer of employment, if such is made, may be withdrawn, with or without prior notice at any time at the option of the company or myself.

I have read, understand and agree to the above.

Electronic Signature:(First name, Last Name, Middle Initial)

Date:

DISCLOSURE AND AUTHORIZATION TO OBTAIN INFORMATION

In connection with my suitability for employment with Avalon Hospice & Palliative Care (“Avalon Hospice & Palliative Care”), I authorize Company to request a consumer and/or investigative consumer report on me for employment purposes from KROLL BACKGROUND AMERICA, INC. (“Kroll”). Such reports may include, but are not limited to, information as to my character, general reputation, personal characteristics, and mode of living; discerned through employment and education verifications; personal references and interviews; my personal credit history based on reports from any credit bureau; my driving history, including any traffic citations; workers’ compensation records after a conditional job offer has been extended and to the extent permitted by law; a social security number trace; present and former addresses; criminal and civil history/records; and any other public record.

I authorize any person, business entity or governmental agency that may have information relevant to the above to disclose the same to Company and Kroll, including, but not limited to, any and all courts, public agencies, law enforcement agencies and credit bureaus. I authorize Company to share such information only with parties in interest who have a “need to know” such information to protect them and their employees. Kroll does not sell or otherwise provide any of the information found in its background investigations to any party other than the Company.

I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any consumer report of which I am the subject upon my written request to Kroll. I also understand that I may receive a written summary of my rights under 15 U.S.C. § 1681 et. seq. I agree that this authorization shall remain valid for the duration of my employment with Company. I certify that the information contained on this Authorization form is true and correct and that my application or employment may be terminated based on any false, omitted or fraudulent information.

Signature

Date:

IDENTIFYING INFORMATION FOR CONSUMER REPORTING AGENCY

Last Name:

First Name:

Middle:

Other Names Used:

Years Used:

Current Address: Street P.O. Box:

City:

State:

Zip Code:

Country:

Dates:

Former Address: Street P.O. Box:

City:

State:

Zip Code:

Country:

Dates:

Social Security Number:

Daytime Phone Number:

Email Address:

Driver’s License Number:

State of Issuance:

Date of Birth

Gender

For CA, MN & OK Residents Only: Please provide me with a copy of my background report

YesNo

For California residents: Under § 1786.22 of the California Civil Code, you may view the file maintained on you by Kroll. You may also obtain a copy of this file, upon submitting proper identification and paying the costs of duplication services, by submitting a request by mail, by appearing at Kroll’s offices in person during normal business hours and on reasonable notice, or you may also receive a summary of the file by telephone after submitting a written request. Kroll has trained personnel available to explain your file to you and will provide a written explanation of any coded information. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification. Kroll is located at 100 Centerview Drive, Suite 300 , Nashville , TN 37214 and may be contacted at 1(888) 381-7866.

*Providing year of birth and gender is strictly voluntary. This information will enable us to properly identify you in the event we find adverse information during the course of a background search.

Copyright © 2008 Kroll Background America, Inc. All Rights Reserved.

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