Employment Application

Date of Application:

Referral Source:

Position(s) Applied For:

Personal Information

Name

First Middle Last

Address

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

Email

Phone

Social Security Number:

Have you filled an application here before?

Yes
No

If Yes, give date:

Have you ever been employed here before?

Yes
No

If Yes, give date:

Are you employed now?

Yes
No

May we contact your present employer?

Yes
No
N/A

Have you filled an application here before?*

Yes
No

On what date would you be available for work?

Are you available to work:*

Full-Time
Part-Time
Shift Work
Temporary

Are you on a lay-off and subject to recall?*

Yes
No

Can you travel if a job requires it?*

Yes
No

Have you been convicted of a felony within the last 7 years?*

(Conviction will not necessarily disqualify applicant from employment.) If Yes, Please explain

Yes
No

If yes, please explain

If hired, would you have a reliable means of transportation to and from work?*

Yes
No

Are you at least 18 years old?*

(If under 18, hire is subject to verification that you are of minimum legal age.)

Yes
No

If hired, can you present evidence of your U.S. Citizenship or proof of your legal right to live and work in this country?*

Yes
No

Are you able to perform the essential functions of the job for which you are applying?*

Yes
No

If No, describe the functions that cannot be performed

Employment Experience
Start with your present or last job. Include military service assignments and volunteer activities.
Exclude organizational names that indicate race, color, religion, sex or national origin.
Last or Present Job

Employer

Address

Telephone

Job Title

Supervisor

Hourly Rate/Salary

Starting

Final

Employed

From

To

Reason for Leaving:

Work Performed:

Previous Job

Employer

Address

Telephone

Job Title

Supervisor

Hourly Rate/Salary

Starting

Final

Employed

From

To

Reason for Leaving

Work Performed

Previous Job

Employer

Address

Telephone

Job Title

Supervisor

Hourly Rate/Salary

Starting

Final

Employed

From

To

Reason for Leaving

Work Performed

Special Skills and Qualifications

Summarize special skills and qualifications acquired from employment or other experience.

Veteran of the U.S. Military service?

Yes
No

If Yes, Branch

Indicate languages you speak, read, and/or write.

List professional, trade, business or civic activities and offices held.

(You may exclude those that indicate race, color, religion, sex or national origin)

Give name, address and telephone number of three references who are not related to you and are not previous employers.

Reference 1

Name

Address

Telephone

Reference 2

Name

Address

Telephone

Reference 3

Name

Address

Telephone

Answer the following questions if you are applying for a professional position.

Are you licensed/certified for the job applied for?

Yes
No

Name of License/certification

Issuing State

License/Certificate Number

Has your license/certification ever been revoked or suspended?

Yes
No

If yes, state reason(s), date of revocation or suspension and date of reinstatement.

Education

Elementary

School Name

Years Completed

Year Graduated

Diploma/Degree

Describe Course of Study

Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities

Honors Received

High School

School Name

Years Completed

Year Graduated

Diploma/Degree

Describe Course of Study

Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities

Honors Received

College/University

School Name

Years Completed

Year Graduated

Diploma/Degree

Describe Course of Study

Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities

Honors Received

Graduate/Professional

School Name

Years Completed

Year Graduated

Diploma/Degree

Describe Course of Study

Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities

Honors Received

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

Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application of employment as may be necessary in arriving at an employment decision. I understand that this application is not and is not intended to be a contract of employment.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

Digital Signature

Date

I hereby certify that I have not knowingly withheld and information that might adversely affect my chances 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. I understand that any omission or misstatement of material fact on this application or any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

*

Initial

I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

*

Initial

I hereby agree to submit to binding arbitration all disputes and claims arising out of the submission of this application. I further agree, in the event that I am hired by the company, that all disputes that cannot be resolved by informal internal resolution which might arise out of my employment with the company, whether during or after that employment, will be submitted to binding arbitration. I agree that such arbitration shall be conducted under the rules of the American Arbitration Association. This application contains the entire agreement between the parties with regard to dispute resolution, and there are no other agreements as to dispute resolution, either oral or written.

*

Initial

I understand that nothing contained in the application, or conveyed during any interview that may be granted or during my employment, if hired, is intended to create an employment contract between the company and me. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company’s designated representative.

*

Initial

I understand that nothing contained in the application, or conveyed during any interview that may be granted or during my employment, if hired, is intended to create an employment contract between the company and me. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company’s designated representative.

*

Initial

I understand that employment at Hospice of Yuma is “at will,” both for the employee and the Hospice. Either the employee or Hospice of Yuma may terminate the relationship at any time, with or without cause.

*

Initial

Digital Signature

Date