Application for Employment

Hospice of Yuma is an Equal Opportunity Employer and supports a Drug Free Work Environment.


Date of Application: Referral Source:
Position(s) Applied For:

Personal Information

First Name: Middle Name: Last Name:
Address:
City: State: Zip Code:
Mailing Address (if different than Address):
Email:
Telephone: Social Security Number:

Have you filed 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
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?
Yes  No
(Conviction will not necessarily disqualify applicant from employment.)
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?
Yes  No
(If under 18, hire is subject to verification that you are of minimum legal age.)
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.

Speak: Read: Write:
Speak: Read: Write:
Speak: Read: 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 for 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

Please Read Carefully, Initial Each Paragraph and Sign Below

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.
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.
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.
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.
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.
Digital Signature:
Date

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