Get Hired - Inspiration Hospice

Inspiration Hospice & Home Health Application for Employment

We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the organization.

Name*

Email*

Date

Position(s) applied for or type of work desired:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of employment desired:

Full Time
Part Time
Temporary

Phone

Date

Are you able to meet the attendance requirements?

Yes
No

Do you have any objection to working overtime if necessary?

Yes
No

Can you travel if required by this position?

Yes
No

Have you ever been previously employed by our organization?

Yes
No

Can you submit proof of legal employment authorization and identity?

Yes
No

If you are under 18, can you furnish a work permit if it is required?

Yes
No

Have you ever been convicted of a crime in the last 7 years?

Yes
No

Driver’s license number (if driving is an essential job duty):

How were you referred to us?

Employment History

Please provide all employment information for your past four employers starting with the most recent.

Employer

Position held

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Immediate supervisor and title

Date employed from

Date employed to

Job summary

Reason for leaving:

Other Skills and Qualifications

Please provide all employment information for your past four employers starting with the most recent.

Summarize any job-related training, skills, licenses, certificates, and/or other qualifications

Educational History

List school name and location, years completed, course of study, and any degrees earned

High school

College

Technical Training

Other

References

List 3 references’ names, telephone numbers, and years known (do not include relatives or employers)

1

2

3

Self Declaration

I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law. I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the ADA. I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment. I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

Applicant Signature

Max. file size: 512 MB.

Date

Inspiration Hospice & Home Health Application for Employment

Employment History

Other Skills and Qualifications

Educational History

References

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