Job Application

Application of Employment

ULTIMATE GREAT CARE HOSPICE does not discriminate in hiring or employment on the basis of race, color, religious creed, national origin, ancestry, sex, or on the basis of age or physical or mental handicap unrelated to the ability to perform the work required. No question on this application is intended to obtain information to be used for such discrimination. This application will be given every consideration. However its acceptance does not imply that the applicant will be employed.

Step 1 of 4

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Personal Information
Name
FirstLast
Social Security Number:
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Phone
Cell Phone
Date Available
If not a U.S. citizen, do you have the legal right to remain permanently and work in the U.S?
- Yes
- No
If you cannot be reacehed at the above phone number, how may we contact you?
Name of person
Phone of person

Education
Grammar or Grade School (Name of School, Location,courses taken, Date Completed, Diploma - Degree or Certificate Received
Example: Reseda Middle School, Reseda CA General Grade Education Completed on 07/05/2006 Middle School Graduate
High School (Name of School, Location,courses taken, Date Completed, Diploma - Degree or Certificate Received
Example: Canoga High School, Canoga CA General High School Education Completed on 07/05/2009 High School Diploma
College (Name of School, Location,courses taken, Date Completed, Diploma - Degree or Certificate Received
Example: CSUN, Northridge CA Mayor in Biology and minor in Administration Completed on 07/05/2012 Bachelor Degree in Biology
Professional Education (Name of School, Location,courses taken, Date Completed, Diploma - Degree or Certificate Received
Example: XYZ College Woodland Hills CA Treating Patients with respect and Compassion Seminar Completed on 10/05/2012 Certificate of compassion care
Laboratory or X-ray Trng. (Name of School, Location,courses taken, Date Completed, Diploma - Degree or Certificate Received
Example: XYZ College Woodland Hills CA Xray Technician Completed on 12/05/2012 Certificate of Xray technician
Extracurricular Activities while in School
Member of Professional Organizations
Honors Received, Volunteer or Community Service or Other Qualifications You Have which you feel are related to the position for which you are applying
have you ever been in the US Armed Forces?
- yes
- no
What is your Present Selective Service Classification?
Are you Presently a member of Reserve or National Guard?
- yes
- no
If So, When is your enlistment Up?
Professional License and / or Certifications
Type of license or certification
Organization or State Issued
Date Issued
Number of License
Certification 2
Type or Licese or Certification 2
Organization or State Issued (2)
Date Issued
Number of License

Employment Record
Employer 1
Name
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Supervisor's Name
FirstLast
Phone
From
To
Salary Range Starting:
Ending
Position & Duties
Reason for leaving
Employer 2
Name
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Supervisor's Name
FirstLast
Phone
From
To
Salary Range Starting From
Ending
Position & Duties
Reason for Leaving
Employer 3
Name
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Supervisor's Name
FirstLast
Phone
From
To
Ending
Ending
Reason for Leaving
Reason for Leaving
Section Break
Please explain all periods of unemployment
Other names you have been known (for date and verification purposes)
FirstLast
Have you ever been convicted of a crime?
- yes
- no
If yes, When and Where?
Please list two references other than relatives or previous employers.
Name and Occupation How do you know them and for how long? Phone Number
Do you consider yourself to be able to perform all the duties required by the job(s) for which you are making an application without endangering yourself, other employees or patient?
- yes
- no
If no, please explain
Read Carefully and send the form: I certify that the information contained in this application is correct to the best of my knowledge, and I understand that any misstatement or omission of information is grounds for ending the hiring process or dismissal. I authorize verification of information provided on this application; and authorize the references listed above to give you all pertinent information concerning my previous employment; and release all parties from all liability for any damages. In consideration of my employment, I agree to conform to the rules and regulations of Sky Hospice I further agree that either I or the Company may terminate my employment with or without cause and with or without prior notice, at anytime. Finally, I understand that no representative of the Company other than an Executive Officer has the authority to enter into any agreement for employment for any specified period or time, or to otherwise alter the foregoing.*
- I Agree

Application of Employment

Step 1 of 4

Personal Information

If you cannot be reacehed at the above phone number, how may we contact you?

Employment Desired

Education

Professional License and / or Certifications

Certification 2

Employment Record

Employer 1

Employer 2

Employer 3

Section Break