Job Application

Last Updated Apr. 27, 2009

Main Section

(scroll down when needed, "*" denotes required feilds)

Your Name: (last, first, mi)
*

Your Address:
*
Your Telephone Number(s):
*

Your Email:
*

Attention:
*

Position Applying For:
*

How did you hear about Joseph Richey Hospice?

* 1. If you are under 18 years of age, can you provide required proof of your eligability to work?

* 2. Have you ever filed an application with us before?
* 3. Have you ever been employed with us before?

* 4. Are you currently employed?

* 5. May we contact your present employer?

* 6. Are you prevented from lawfully becoming employed in this country because of visa or immigration status? (Proof of citizenship or immigration status will be required upon employment.)

* 7. On what date will you be available for work?

* 8. Are you available to work:
Full Time? Part Time? Shift Work?
Temporary?

9. Are you currently on "lay-off" status and subject to recall?

10. Within the past five years, have you been convicted of a felony, or within the past two years, of any misdemeanor, or are you presently charged (formally) with commiting a criminal offense?(Do not include any traffic violations, juvenile offenses or military conviction, except by court martial. If yes please fill in comments section.)
comments:

11. In the past three years, have you ever knowingly used narcotics, amphetamine, or barbituates, other than those prescribed to you by a physician?

12. In the past three years, have you ever knowingly used any non-physician prescribed "street drugs"?

Education Section

(scroll down when needed)

Years completed of school:
Senior High School
Undergraduate Collage/University
Graduate/Professional

Please list any languages OTHER than English that you know. Please also indicate how well you know them, and weather or not you can read/write in them.


List any professional, trade, business, or civic activities and offices held. You may exclude membership which would reveal sex, race, religion, national origin, age, ancestry or handicap or other protected status:


Personal References:


Please give name, address (including zip code) and telephone number of three references that arae not related to you and are not previous employers

1.

2.

3.


Have you ever had any job-training in the US military?
If yes, please describe:

Are you physically or otherwise unable to perform the duties of the job for which you are applying?

Employment Experience



Start with your present or most recent job. Include any job-related military service assignments and volunteer activities. You may exclude organizations, which race, color, religion, gender, national origin, handicap or other procted status.
1. Employer Name:
    telephone:
    address:
    dates employed:to
    job title:
    work performed:
    Salary:
    Reason for leaving:


2. Employer Name:
    telephone:
    address:
    dates employed:to
    job title:
    work performed:
    Salary:
    Reason for leaving:


3. Employer Name:
    telephone:
    address:
    dates employed:to
    job title:
    work performed:
    Salary:
    Reason for leaving:


4. Employer Name:
    telephone:
    address:
    dates employed:to
    job title:
    work performed:
    Salary:
    Reason for leaving:


5. Employer Name:
    telephone:
    address:
    dates employed:to
    job title:
    work performed:
    Salary:
    Reason for leaving:

List any special skills or qualifications:



(We consider applicants for all positions without regard to race, color, religion, sex national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.)