Job Application - HA | Hospice Providers of the Desert

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Welcome to our Employment Application!

An Equal Opportunity Employer

We’re thrilled you’re here. Take your time filling it out; we can’t wait to learn more about you. If you need help, our HR team is here for you. Good luck!

By proceeding you agree to Hospice Providers of the Desert’s Privacy Policy.

PERSONAL INFORMATION

First Name *

Middle Name

Last Name *

Phone *

Email Address *

Social Security Number *

Date of Birth *

Emergency Contact Person *

Phone *

Street Address *

Apartment, suite, etc

City *

State *

ZIP Code *

Position Applying For *

Availability to Work *Full TimePart TimeOn-Call / Per VisitOthers

What Days and Hours are you available for work? *

Would you be available to work overtime if necessary? *YesNo

If hired, on what date can you start? *

Wages desired *

Have you ever applied or worked for HOSPICE PROVIDERS OF THE DESERT, INC. before? *YesNo

If yes, give date(s)

How did you hear about us? *

Have you ever been excluded from participating in the Medicare/Medicaid Program? *YesNo

Why are you applying for work at HOSPICE PROVIDERS OF THE DESERT, INC.? *

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

Are you at least 18 years of age? *YesNo

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

Have you ever been convicted of criminal offense (felony or serious misdemeanor; convictions for marijuana-related offenses that are more than two years old need not be listed)? *YesNo

If yes, state the nature of crime(s), when and where convicted and disposition of the case: *

NOTE: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position applied for may, however, be considered.

Are you currently employed? *YesNo

May we contact your current/former employer? *YesNo

EDUCATION & TRAINING

High School (School Name & Address) *

No. of Yrs Completed *

Did you graduate? *YesNo

Year Graduated *

College (School Name & Address) *

No. of Yrs Completed *

Did you graduate? *YesNo

Year Graduated *

Vocational (School Name & Address) *

No. of Yrs Completed *

Did you graduate? *YesNo

Year Graduated *

Health Care (School Name & Address) *

No. of Yrs Completed *

Did you graduate? *YesNo

Year Graduated *

Others (School Name & Address)

No. of Yrs Completed

Did you graduate?YesNo

Year Graduated

Some clients do not speak English. Do you speak another language, other than English? *YesNo

Language(s):EnglishChineseHindiSpanishTagalogArabicRussianUrdu

Others

Do you have any experience, training, qualifications, or skills which you feel make you especially suited for the work at HOSPICE PROVIDERS OF THE DESERT, INC.? If so, please explain: *

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

Are you Licensed/Certified? *YesNo

Profession *Nurse PractitionerRNLVNSocial WorkerChaplain/Spiritual CounselorCertified Nursing AssistantOthers

License/Certification Number:

Has your License/Certification ever been revoked or suspended? *YesNo

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

EMPLOYMENT HISTORY

Please list below all present and past employment starting with your most recent employer (for at least the last five years); use back of the paper if necessary. Account for all periods of unemployment:

Name of Employer *

Address *

Supervisor's Name

From: *

To: *

Position Held *

Wage

Reason for Leaving *

Name of Employer *

Address *

Supervisor's Name

From *

To *

Position Held *

Wage

Reason for Leaving *

Name of Employer *

Address *

Supervisor's Name

From *

To *

Position Held *

Wage

Reason for Leaving *

MILITARY SERVICES

Have you obtained any special skills or abilities as the result of service in the military? *YesNo

If yes, please describe:

REFERENCES

List below three persons not related to you, who have knowledge of your work performance within the last three years.

Name *

Address *

Occupation

Phone *

No. of Years Acquainted

Name *

Address *

Occupation

Phone *

No. of Years Acquainted

Name *

Address *

Occupation

Phone *

No. of Years Acquainted

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I certify that the information provided in this job application is true and accurate to the best of my knowledge. I understand that any false statements or omissions may result in disqualification from employment or termination if already hired.

Signature *

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Date

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