CAREERS

Employment Application

Applicant Note: This application form is intended for use in evaluating your suitability for employment. Please answer all questions completely and legibly. If a question is not applicable, indicate with N/A. False or misleading statements, whether oral or written, are grounds for refusal or termination of employment and benefits. All qualified applicants will receive consideration without discrimination on the basis of sex, age; race, national Origin, citizenship, disability, or any other status protected under state or federal law, and such Information may be omitted from this form. A felony conviction will not necessarily disqualify an applicant from employment.

Personal Data:

First Name*

Last Name*

Social Security Number

Home Phone Number

Cell Phone Number*

Email*

Address Information:

Street*

City*

State*

Zip*

Since(MO/YR)*

Add Another Address

Delete

Availability:

Position Applied For*

Date you can start work*

Do you prefer*

Full Time

Part Time

Per Diem

Can you work

Evenings

Weekends

Please answer the following questions, when necessary, note question number and use the extra space to provide explanations:

Are you at least 18 years old and legally eligible for work in the United States?*

YES

NO
Are you party to any noncompetition trade agreement?*

YES

NO
If "Yes", please explain:
Have you ever been convicted or plead guilty to a felony or other crime?*

YES

NO
If "Yes", please explain:
Have you been given a description of the job for which you are applying or had the essential elements of the job explained to you?*

YES

NO
Do you understand the job requirements?*

YES

NO
Will you work overtime when necessary?*

YES

NO
Are you on layoff and subject to recall?*

YES

NO

Education:

High School*

City*

State*

Dates*

college diploma

City

State

Dates

Graduate School Attended Diploma

City

State

Dates

Trade, Business, or Other School Diploma

City

State

Dates

Employment Experience

Most Recent Employer*

City*

State*

Phone Number*

Position Held*

Dates From*

Dates To*

Pay Rate upon Leaving*

Supervisor*

Duties*

Reason for leaving

Add Another Employment

Delete

References

Two professional references:

First Name*

Last Name*

Relationship*

Address

Phone*

First Name*

Last Name*

Relationship*

Address

Phone*

Have you ever applied with or worked for this company or one of Its corporations before?*

YES

NO
Please list any other companies in this industry for whom you have worked
Have you ever served in any branch of the USA Military?*

YES

NO
If you answered yes, please list
It is our policy to contact all employers listed above for references. Please note here those employers listed whom we may NOT contact:
Comments

Emergency Contact:

First Name*

Last Name*

Relationship*

Address

Phone*

First Name

Last Name

Relationship

Address

Phone

Job - Related Skills

Do you have a valid Driver's License?*

YES

NO
Are you familiar with medical terminology?*

YES

NO
Please use the space below to describe any special study areas study of research you have completed or participated in:
Please list any professional licenses, designations, certifications, etc. that may relate to the position applied for. Include date granted name of the organization, any other information:

Days you are available to work

Please inform the agency of the days you are available to work for HOSPICE AGENCY OF NJ, INC.

First Name*

Last Name*

Effective Date*

Yes

Sunday*

Monday*

Tuesday*

Wednesday*

Thursday*

Friday*

Saturday*

Criminal Background Check:

To define the process in which HOSPICE AGENCY OF NJ, Inc., ensures all employees with direct patient care are free of State Guidelines for Criminal Backgrounds.

Policy:

HOSPICE AGENCY OF NJ, Inc. will ensure that each applicant that will have direct care with clients, be given the name and address of an agency to have their Criminal Background checked. All pre-hire professional staff shall have a copy of their Professional License retained in their personnel file and will be updated as necessary, as well as the (BID) and/or (DOJ) background check.

Procedure:

The applicant will be able to start work in good faith for up to (30) thirty days from date of hire pending the outcome of the Background check. The applicant is responsible for the fee of the Criminal Background Check pending the outcome.

It is mandatory that all direct patient care employees hired by HOSPICE AGENCY OF NJ, Inc . must obtain a (BID) Criminal Background check, DOJ check, and an out of state check if deemed necessary.

All fees for the (DOJ) Background checks will be reimbursed on the first paycheck after the completion of the (90) ninety day probationary period.

In the event the Criminal Background Check comes back with any provisions according to the rules of employment, the employee will be terminated by HOSPICE AGENCY OF NJ, Inc. This is a violation of the (90) day probationary period.

This Policy/Procedure shall be reviewed annually by the Professional Advisory Committee (PAC).

I Agree

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Certification:

I certify that I have read the instructions and applicant note on page one of this form that the answers given by me herein are true and complete to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment.

I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I understand that should I be employed, that employment shall be on a probationary basis for a period of 90 days from date of hire. I further understand that completion of the probationary period will not result in any employment contract, or employment for any specific term, but that I shall remain employed solely on understanding that my employment relationship is terminable an at-will, regardless of any oral representation to the contrary. Both Company and I remain free to choose to end relationship at any time for any or no reason. Any changes to this employment relationship must be made in writing.

I also understand that the use of illegal drugs is prohibited during my employment. If company requires, I am willing to submit to drug testing to detect the use of illegal drugs before and during employment.

I understand that this application will be considered for a period of study of (60) days and that if you do not then employ me, it will be necessary for me to complete another application form in order to receive further consideration

I Agree

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Careers

Hospice Careers

Employment Application

Personal Data:

Address Information:

Availability:

Do you prefer*

Can you work

Please answer the following questions, when necessary, note question number and use the extra space to provide explanations:

Education:

Employment Experience

References

Two professional references:

Emergency Contact:

Job - Related Skills

Days you are available to work

Please inform the agency of the days you are available to work for HOSPICE AGENCY OF NJ, INC.

Criminal Background Check:

Policy:

Procedure:

Upload your resume here:

Upload Your Resume:

Certification: