Mountain Hospice Employment Application Form Click here to download the PDF version of our Employment Application Form. Step 1 of 7 14% Applicant InformationDate of Application* MM slash DD slash YYYY Name* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home or Cell Number*Last 4 Digits of SSN*Email* Position Applied For*Where did you hear about Mountain Hospice and/or this opening?*Professional License Number (if applicable)Professional License State (if applicable)Are you currently employed?* Yes No If you are currently employed, by whom?Current Rate of PayEmployer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code On what date would you be available to begin?* MM slash DD slash YYYY Choose all that apply:* Full-time Part-time PRN (as needed) Are you under 18 years of age?* Yes No Are you legally authorized to work in the United States?* Yes No Have you been convicted of a felony*?* Yes No *A criminal conviction listed on the application will not disqualify an applicant. Mountain Hospice will consider:Â the nature or gravity of any offense or conduct; the time elapsed since the conviction and/or completion of any jail sentence; and the responsibilities of the job being filled.If you have been convicted of a felony, when? MM slash DD slash YYYY EducationHigh SchoolCollegeNumber of Years Attending CollegeCollege Degree(s)Major Course of StudyAdvanced DegreesCollege/UniversityTrade, Business or Correspondence School(s)Trade, Business or Correspondence School(s) SubjectsDid you complete course(s)? Yes No Keyboard WPM?List your working knowledge of office machines:Other skills/training:List other experience, volunteer activities, course, workshops and seminars which may be applicable to the position applied for: Employment RecordStarting with your present or last job, list your work experience.Employment 11. Employed by:1. Dates Employed:1. Phone Number:1. Job Title:1. Pay Rate:1. Supervisor:1. Reason for Leaving:Employment 22. Employed by:2. Dates Employed:2. Phone Number:2. Job Title:2. Pay Rate:2. Supervisor:2. Reason for Leaving:Employment 33. Employed by:3. Dates Employed:3. Phone Number:3. Job Title:3. Pay Rate:3. Supervisor:3. Reason for Leaving:Employment 44. Employed by:4. Dates Employed:4. Phone Number:4. Job Title:4. Pay Rate:4. Supervisor:4. Reason for Leaving:List any military experience: ReferencesGive name, complete mailing address, email address and telephone number of three professional references that are not related to you. These should be individuals you have worked with previously or currently.Reference 1Reference 1 Name* First Last Reference 1 Phone*Reference 1 Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference 1 Email* Reference 2Reference 2 Name* First Last Reference 2 Phone*Reference 2 Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference 2 Email* Reference 3Reference 3 Name* First Last Reference 3 Phone*Reference 3 Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference 3 Email* Physical RequirementsPlease refer to position description for which you are applying. Can you perform the essential functions of the job for which you are applying with or without reasonable accommodation(s)?* Yes No If no, what can be done to accommodate? Application DisclaimerThe facts set forth in my application for employment are true and complete. I understand that any false statement on this application may result in my rejection as a candidate or immediate dismissal if employed. I further understand that this application is not and is not intended to be a contract of employment, nor does this application obligate Mountain Hospice, Inc., in any way. Furthermore, I understand that if I am hired, my employment is at-will and can be terminated with or without cause at any time, at the discretion of either the company or myself.I hereby give permission to contact the previous employers and character references that I have listed except for the particular employer(s) noted (please provide reasoning):I understand that by filling out this application that I will not be guaranteed a job and I also understand that this application will only be considered for one (1) year from date of receipt unless I contact the Director of Human Resources for Mountain Hospice in writing on a continuous basis that I am still available for employment. Mountain Hospice provides equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, veteran status or any other status protected by local, state and federal law. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.Date* MM slash DD slash YYYY Signature* Personal Information ReleaseI do hereby authorize Mountain Hospice, Inc., to secure any necessary information from all my employers, references, neighbors, academic, training, or vocational institutions, etc. I understand that background checks will be completed for all new employees. I hereby release all individuals providing said information including but not limited to employers, references, neighbors, academic, training or vocational institutions and Mountain Hospice, Inc., from any and all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications, and my suitability for employment with Mountain Hospice, Inc.Date* MM slash DD slash YYYY Signature* Δ
