test career form

test.

Position(s) Desired:

Name (Last/First/Middle):

Address

City

State

Zip

Phone

Email

Referred By:

Education

High School

College

Other

Special Training or Skills:

Current or past licensure or certification held by New York State or other states/countries:

License 1:

State:

License 2:

State:

Related skills:

Are you employed now? YesNo

When would you be available to begin work if offered a position of employment?

Have you ever been employed by Hospicare?YesNo
Date:

Have you ever volunteered at Hospicare? YesNo
Date:

Why are you interested in working for Hospicare?

Do you have transportation? YesNo

Do you have a current NYS driver’s license and current insurance? YesNo

Have you ever been convicted of a criminal offense? YesNo
If yes, please explain:

Employment Record (please list more recent job first)

Employer 1

Name and address of employer:

Employment Dates (Month/Year):
From
To

Your job title and major duties:

Reasons for leaving:

Is it OK to contact employer for reference?
YesNo

Person to contact for work reference (immediate supervisor):
Name
Phone

Employer 2

Name and address of employer:

Employment Dates (Month/Year):
From
To

Your job title and major duties:

Reasons for leaving:

Is it OK to contact employer for reference?
YesNo

Person to contact for work reference (immediate supervisor):
Name
Phone

Employer 3

Name and address of employer:

Employment Dates (Month/Year):
From
To

Your job title and major duties:

Reasons for leaving:

Is it OK to contact employer for reference?
YesNo

Person to contact for work reference (immediate supervisor):
Name
Phone

Additional references

(please do not use relatives). Please include at least three.

Reference 1 -

Name

Occupation

Email

Phone

Years Known

Reference 2 -

Name

Occupation

Email

Phone

Years Known

Reference 3 -

Name

Occupation

Email

Phone

Years Known

PLEASE READ CAREFULLY BEFORE SIGNING:

I understand that all statements made here are subject to verification by Hospicare & Palliative Care Services, and I release, indemnify and hold harmless Hospicare from and against all liability which might result from making such a verification or investigation. For all positions, the investigation will include a criminal history record check. I agree that the contents of this application form and related reports may be used by Hospicare in any manner it may wish. I further understand that misrepresentation of facts is sufficient cause for rejection of this application or discharge if I am later employed. I further understand that if I am under 18 years of age, and if I am hired, I must furnish to Hospicare documents sufficient to demonstrate identity and eligibility to work in the United States, as required by the Immigration Reform and Control Act of 1986.

I understand nothing contained in this application or in the granting of an interview is intended to create an employment contract between Hospicare and me for either employment or for the granting of benefits. No promises regarding employment have been made to me and I understand that no such promise or guarantee is binding upon Hospicare unless made in writing. If an employment relationship is established, I understand and agree that it is not for a definite period of time and that I have the right to terminate my employment at any time and that Hospicare retains a similar right. I further understand that if I am hired, the first three months of employment will be a probationary period, and that I must satisfactorily complete a 3-month period of employment before I am classified as a regular employee and become entitled to the benefits of that classification.

Signature

Date