Join Our Team - Stillwater Hospice

Application for Employment

Personal Information

Name

First Name: Middle Name: Last Name:

Email*

Home Telephone #:

Daytime Telephone #:

Date of Application: (MM/DD/YYYY)

Location Site*

Address

Residence Address: Apt. #: City: State: Zip Code:

Address

Mailing Address: Apt. #: City: State: Zip Code:

Employed with us

Have you even been employed with us before? If yes, when and reason for leaving?

Yes
No

Able to Work

Are you able to work:

Full-Time
Part-Time
Per Diem
Seasonal

Yes/No One

Are you prevented from lawfully becoming employed in this country beauase of VISA or Immigration status? (Proof of citizenship or immigration status will be required upon employment)

Yes
No

Yes/No Two

Have you been convicted of a felony within the last 7 years? (Conviction will not necessarily disqualify an applicant from employment.) If "YES", please explain.

Yes
No

Yes Reason

Yes, Please Explain

Employment Desired

Position:

Currently employed

Are you Currently Employed?

Yes
No

Inquire

May we inquire of your present employer?

Yes
No

Date You Can Start:

Salary Desired:

Annual/Hourly

Annual / Hourly

Annual
Hourly

Referrer

Who Referred you to this company:

Employment Agency:
Recruitment Fair/Mailing:
College Posting:
Newspaper Advertisement:
Professional Journal:
Friend/Relative:
Other:

Referrer Fill in

Education

High School:

Undergraduate:

Graduate Professional:

Other: (Please specify)

General Information

Areas of Experience:

Employment Experience

Starting with your present or last job. Include any job-related military service assignments, and volunteer activities. You may exclude organizations, which indicate race, color, religion, gender, national origin, disabilities, or other protected status.

Employer:

Previous Employment #1:

Employment Dates:

Address:

Hourly Rate/Salary

Hourly Rate/Salary:

Job Title:

Supervisor:

Work Performed:

Employer:

Previous Employment #2:

Employment Dates:

Address:

Hourly Rate/Salary

Job Title:

Supervisor:

Work Performed:

Employer:

Previous Employment #3:

Employment Dates:

Address:

Hourly Rate/Salary

Job Title:

Supervisor:

Work Performed:

References

Name

Reference #1:

Address

Business

Phone Number

Years Acquainted

Name

Reference #2:

Address

Business

Phone Number

Years Acquainted

Name

Reference #3:

Address

Business

Phone Number

Years Acquainted

Attach A Resume

Resume

Formats: .pdf, .txt, .doc, .docx, .rtf

Applicant's Statement

"I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time during the first 6 months. I also understand and agree that the terms and condition of my employment may be changed, with or without cause and with or without notice, at any time by the company. I understand that no company representative, other then it’s president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing. I also understand and agree that my continued employment may be contingent upon the successful completion of a criminal background check”

Applicant Full Name:

Date:

Employment Dispute Resolution Program Agreement

Agreement*

I have read and agree to the terms and conditions of the Employment Dispute Resolution Program

Signature:*

Date:*