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Online Employment Application Form

• Your Contact Information

• Name * First Middle Last
• Address *
  Street Address
  Apartment / Unit #
  City State Zip County
• Home Phone * ### - ### - ####
• Business Phone * ### - ### - ####
• Email Address *
• Last 4 digits of your Social Security No: *
• Will you travel if job requires it?
  Yes No
  If no why?
• Do you have a valid driver's license?*
  Yes No
  Driver's License No: *
• Have you had your driver's license suspended or revoked in the last 3 years?*
  Yes No
  If yes, give details:
• Are you 18 years of age or older? (If you are hired, you may be required to submit proof of age.)*
  Yes No
• If hired, can you furnish proof you are eligible to work in the U.S.?*
  Yes No
• Have you ever applied for employment with us?*
  Yes No
  If yes: Month and Year
• Have you ever worked for this company?*
  Yes No
  If so, location employed and when
• Do you have relatives currently working at Stein Hospice?*
  Yes No
  If yes, whom?
• Have you ever been convicted of a felony or misdemeanor? *
  Yes No
  If yes, give details.
  (A "Yes" answer does not automatically disqualify you from employment, since the nature of the offense, date and the job for which your are applying is also considered.)
• Have you ever pleaded "guilty" or "no contest" to or been convicted of a crime? *
  Yes No
  If yes, please provide date(s) and details.
• Which position are you applying for? *
  Please choose a position IT/Helpdesk Marketing Volunteer Facilitator Social Worker Chaplain H.R. LPN Office Scheduler Massage Therapist Cosmetologist Registered Health Information Technician Art Therapist Anticipatory Grief Counselor RN STNA Other
• Licensure #
• Pay Expected*
• Are you applying for full-time or part-time work?*
  Full-Time Part-Time
• Will you work overtime if asked?*
  Yes No
• Have you ever worked or attended school under any other names?*
  Yes No
  If yes, give name(s)
• When will you be available to begin work? * MM / DD / YYYY
• Other special training or skills (languages, machine operation, etc.)*
• How were you referred to us?*
  Employment Agency
  
  
  Placement Service
  
  
  Walk-In
  
  
  Newspaper
  Please specify
  
  Current Employee
  Please specify
  
  Other
  Please specify

• Education

  High School
  High School Name
  Street Address
  City State Zip
  
  Number of Years Completed
  Did you graduate?
  Yes No
  Degree or Diploma
• College
  College Name
  Street Address
  City State Zip
  
  Course of Study
  Number of Years Completed
  Did you graduate? Yes No
  Degree or Diploma
• Other
  Other School Name
  Street Address
  City State Zip
  
  Course of Study
  Number of Years Completed
  Did you graduate? Yes No
  Degree or Diploma
• Summerize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying:
• Computer Skills (Check approiate boxes. Include software titles and years of experience
  Word Processing
  Years:
  
  Spreadsheet
  Years:
  
  Power Point
  Years:
  
  Internet
  Years:
  
  E-Mail
  Years:
  
  Electronic Charting
  Years:
  
  Typing
  WPM:
  
  Other
  Years:
  

• Employment

  Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer

  Company #1
  Company
  Street Address
  City State Zip
  
  Phone Number
  ### - ### - ####
  
  Employed (mm/yy)
  From To
  
  Name of Supervisor
  
  
  Weekly Pay
  Start Last
  
  State Job Title and Describe Your Work
  Reason for Leaving
  What did you like most about your job?
  What did you like least about your job?
  May we contact your previous supervisor for a reference? Yes No
• Company #2
  Company
  Street Address
  City State Zip
  
  Phone Number
  ### - ### - ####
  
  Employed (mm/yy)
  From To
  
  Name of Supervisor
  
  
  Weekly Pay
  Start Last
  
  State Job Title and Describe Your Work
  Reason for Leaving
  What did you like most about your job?
  What did you like least about your job?
  May we contact your previous supervisor for a reference? Yes No
• Company #3
  Company
  Street Address
  City State Zip
  
  Phone Number
  ### - ### - ####
  
  Employed (mm/yy)
  From To
  
  Name of Supervisor
  
  
  Weekly Pay
  Start Last
  
  State Job Title and Describe Your Work
  Reason for Leaving
  What did you like most about your job?
  What did you like least about your job?
  May we contact your previous supervisor for a reference? Yes No
• Company #4
  Company
  Street Address
  City State Zip
  
  Phone Number
  ### - ### - ####
  
  Employed (mm/yy)
  From To
  
  Name of Supervisor
  
  
  Weekly Pay
  Start Last
  
  State Job Title and Describe Your Work
  Reason for Leaving
  What did you like most about your job?
  What did you like least about your job?
  May we contact your previous supervisor for a reference? Yes No
• Explain any gaps in your employment, other than those due to personal illness, injury or disability:
• If not addressed above, have you ever been terminated or asked to resign from a job?
  Yes No
  If yes, please explain:

• References

  List names and telephone numbers of three business/work references who are not related to you. If not applicable, list, three school or personal references that are not related to you.

  Reference #1
  Name
  Business
  Address
  Phone Number
  ### - ### - ####
  
  Known How Long?
• Reference #2
  Name
  Business
  Address
  Phone Number
  ### - ### - ####
  
  Known How Long?
• Reference #3
  Name
  Business
  Address
  Phone Number
  ### - ### - ####
  
  Known How Long?

• Emergency Contact

  Name
  Address
  Phone Numbers



Authorization

I understand that the information provided in this Application for Employment is true, correct and complete. If employed, any misstatement or omission of fact on this application may result in my dismissal.

I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future.

If you decide to engage an investigative consumer reporting agency to report on my credit and personal history I authorize you to do so. If a report is obtained you must provide, at my request, the name and address of the agency so I may obtain from them the nature and substance of the information contained in the report.

Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age, national origin, handicap or veteran status. Stein Hospice is covered by EEOC laws.

Disclaimer: Completion of application does not guarantee a job or interview for a job. Our application must be completely filled out or will it not be considered. Please do not answer questions with “see resume”. If information can not be satisfactorily verified, application will be considered incomplete. Specific reasons for not hiring will not be released. If you have not heard from us in 10 days a position is not available at that time. All applications will be kept on file for one year.