EOC Last Name First Name M.I.

Transcription

1 DATE EOC Last Name First Name M.I. POSITION APPLIED FOR Telephone Number Cell Phone /Other Contact # Number Of Years At Current Address Social Security Number FACILITY SALARY DESIRED HOME CARE Current Address: Street Apt # City State Zip Are You Authorized To Work In US? YES NO If No, Please Explain: Are You At Least 18 Years Of Age? Yes No If No, Please Indicate Age: (If You Are Under 18 We May Require Proof Of Age & Work Permit.) Shift Preference: Days Nights Evenings Weekends Only Any Days/Hours Not Available To Work: What Date Will You Be Available To Start Work? / / Can You Travel If The Job Requires It? Type Of Employment Desired: Full Time Part Time PRN/Casual Temporary Weekends Only List Any Relatives Employed With Our Company: Relationship: Have You Ever Completed An Application With Us Before? Yes No Date Of Application: Have You Been Employed With Our Company Before? Yes No Employment Dates: How Did You Hear/Learn About Our Company? Advertisement Walk In Referral By Current Employee: Employment Agency Other, Please Specify: Have you ever been convicted or pled nolo contender of a MISDEMEANOR or FELONY, other than minor traffic violations and/or placed on probation, fined or given a suspended sentence in court? YES * NO *Explain below: ( Include any convictions by military trial and any criminal charges for which you are awaiting trial. List all cases other than minor traffic violations. (Driving under the influence, reckless or hit and run driving are not minor traffic violations). Please note: A full disclosure by you is to your advantage, as your record does not constitute an automatic bar to employment. HOWEVER, FAILURE TO ADMIT CONVICTIONS WILL RESULT IN DISQUALIFICATION.)

2 EMPLOYMENT HISTORY In the spaces below, list your employment history beginning with your most recent employer. Please complete even if attaching a resume. Can we contact your present and previous employers: YES NO If no, please list the names of the employer(s) you do not want us to contact: Name and Address of Company Name From To Position/Title Name of Supervisor Street Description of Duties City, State, Zip Reason for Leaving Telephone Number Beginning Salary Ending Salary Days and Hours Worked ( ) Name and Address of Company Name From To Position/Title Name of Supervisor Street Description of Duties City, State, Zip Reason for Leaving Telephone Number Beginning Salary Ending Salary Days and Hours Worked ( ) Name and Address of Company Name From To Position/Title Name of Supervisor Street Description of Duties City, State, Zip Reason for Leaving Telephone Number Beginning Salary Ending Salary Days and Hours Worked ( )

3 EDUCATION AND TRAINING School Name and Location of School Course of Study Years Completed Did you Graduate Certificate or Degree Received High School Yes No College Yes No Graduate School Other Studies Yes Yes No No PROFESSIONAL CERTIFICATES OR LICENSES PROFESSION LICENSE OR REGISTRATION STATE ISSUING LICENSE OR STATE IN WHICH REGISTERED LICENSE NUMBER ADDITIONAL TRAINING Describe any specialized training and / or apprenticeships SKILLS AND QUALIFICATIONS Summarize special job related skills and qualifications acquired from employment or other experiences PERSONAL REFERENCES Give the names of three people (not related to you) whom you have known at least one year. Name: Telephone Number: Name: Telephone Number: Name: Telephone Number:

4 SIGNATURE AND CERTIFICATION I hereby affirm that the information provided on this application (and accompanying resume and/or documentation, if any) is true and complete to the best of my knowledge. I understand that if I am selected for a position, I must be eligible for employment in the US. I also understand that falsified information or significant omissions may disqualify me from further consideration for employment, and may be considered justification for dismissal if discovered at a later date. I further understand that this application becomes property of the Company and will not be returned. I authorize persons, schools, my current and previous employers and organizations named in this application (and accompanying documentation), to provide relevant information that may be required to arrive at an employment decision. In connection with this application for employment, I understand that a consumer report or investigative consumer reports which may contain public record information may be requested or made on me including consumer credit, criminal records, driving record, education, prior employer verification, workers compensation claims and others. These reports will include experience along with reasons for termination of past employment. Further, I understand that the company will be requesting information from various Federal, State, Local and other agencies which contain my past activities. I hereby authorize without reservation, any party or agency contacted by this employer to furnish the above mentioned information. I further authorize ongoing procurement of the above mentioned reports at any time during my employment. DRUG TEST CONSENT (CONSENT FOR PRE-EMPLOYMENT DRUG TEST SCREEN AND RELEASE AGREEMENT) I hereby CONSENT to allow Tidelands Community Hospice to take a specimen of my hair, urine, or blood and submit it for a pre-employment, post-accident, or reasonable suspicion drug test screen. I FURTHER CONSENT to allow the laboratory testing service to make the results of such screen available to the prospective or current employer, Tidelands Community Hospice. In consideration for such services being rendered on my behalf, I hereby release the laboratory testing service, its officers, agents, and employees, from any and all claims which I might otherwise have due to such results being made so available. I hereby consent not to file any action at law or in equity against Tidelands Community Hospice, the laboratory testing service, their respective officers, agents or employees in connection with the results of such screen being made so available, and I hereby agree to indemnify and save harmless Tidelands Community Hospice, the laboratory testing service, their respective officers, agents, and employees from all damages, expenses, reasonable attorney's fees, and costs of court which they or any of them may suffer or incur, jointly or severally, due to the results of such screen being made so available. I also understand that failure to comply with a drug and/or alcohol testing request or a confirmed positive result for the illegal use of drugs and/or alcohol will lead to a disqualification of my application or chance of employment with Tidelands Community Hospice. IF EMPLOYED, I UNDERSTAND THAT: (1) MY EMPLOYMENT WILL BE AT-WILL AND MAY BE TERMINATED BY ME OR THE COMPANY AT ANY TIME, FOR ANY REASON AND WITHOUT NOTICE; (2) REGARDLESS OF ANY REFERENCES TO WAGES AS YEARLY, MONTHLY, OR WEEKLY, MY EMPLOYMENT IS NOT FOR A DEFINITE PERIOD OF TIME; (3) WE MAY REVISE AND MAKE EXCEPTIONS TO THE POLICIES, PRACTICES, HANDBOOKS, MANUALS, RULES, AND REGULATIONS IN WHOLE OR IN PART, AT ANY TIME; AND (4) UNLESS AGREED TO IN WRITING BY THE OWNERS OF THE COMPANY NO WRITTEN OR ORAL STATEMENTS I RECEIVE FROM THE COMPANY WILL CHANGE MY STATUS AS AN AT WILL EMPLOYEE. Signature Date EQUAL OPPORTUNITY EMPLOYER WE ARE A DRUG FREE WORKPLACE AND YOU ARE SUBJECT TO TESTING.

5 APPLICANT S AUTHORIZATION FOR RELEASE OF INFORMATION THIS FORM TO BE COMPLETED AND SIGNED BY JOB APPLICANT *************************************************************** IN CONNECTION WITH MY APPLICATION FOR EMPLOYMENT (INCLUDING CONTRACT FOR SERVICES), I UNDERSTAND THAT CONSUMER REPORTS OR INVESTIGATIVE CONSUMER REPORTS WHICH MAY CONTAIN PUBLIC RECORD INFORMATION MAY BE REQUESTED OR MADE ON ME INCLUDING CONSUMER CREDIT, CRIMINAL RECORDS, DRIVING RECORD, EDUCATION, PRIOR EMPLOYER VERIFICATION, WORKER S COMPENSATION CLAIMS AND OTHERS. THESE REPORTS WILL INCLUDE EXPERIENCE ALONG WITH REASONS FOR TERMINATION OF PAST EMPLOYMENT. FURTHER, I UNDERSTAND THAT YOU WILL BE REQUESTING INFORMATION FROM VARIOUS FEDERAL, STATE, LOCAL AND OTHER AGENCIES WHICH CONTAIN MY PAST ACTIVITIES. I HEREBY AUTHORIZE WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THIS EMPLOYER TO FURNISH THE ABOVE MENTIONED INFORMATION. I HAVE THE RIGHT TO MAKE REQUEST OF THE BACKGROUND CHECK COMPANY, UPON PROPER IDENTIFICATION AND THE PAYMENT OF ANY AUTHORIZED FEES, FOR THE INFORMATION IN THEIR FILES ON ME AT THE TIME OF MY REQUEST. I FURTHER AUTHORIZE ONGOING PROCUREMENT OF THE ABOVE MENTIONED REPORTS AT ANY TIME DURING MY EMPLOYMENT (OR CONTRACT). I UNDERSTAND THAT, PURSUANT TO THE FEDERAL FAIR CREDIT REPORTING ACT, THE EMPLOYER WILL PROVIDE ME WITH A COPY OF ANY SUCH REPORT IF THE INFORMATION CONTAINED IN SUCH REPORT IS, IN ANY WAY, TO BE USED IN MAKING A DECISION REGARDING MY FITNESS FOR EMPLOYMENT WITH THE EMPLOYER. I FURTHER UNDERSTAND THAT SUCH REPORT WILL BE MADE AVAILABLE TO ME, ALONG WITH THE NAME AND ADDRESS OF THE REPORTING AGENCY THAT PRODUCED THE REPORT. PRINT FULL NAME PREVIOUS LAST NAMES SOC. SEC. NUMBER - - DATE OF BIRTH (DOB IS REQUESTED TO ENSURE ACCURATE RETRIEVAL OF RECORDS.) CITY AND STATE OF BIRTH DRIVER S LICENSE NUMBER STATE OF ISSUE CURRENT ADDRESS CITY, STATE, ZIP PREVIOUS ADDRESS IF AT ABOVE FOR LESS THAN ONE YEAR: CITY, STATE, ZIP APPLICANT S SIGNATURE DATE *************************************************************************************************** THE COMPANY: REQUESTOR: _ RETURN FAX OR brittany.cromedy@strovis.com CA, MN, OK, and NY applicants only: please check here to have a copy of your consumer report sent directly to you by InfoQuest, Inc V5.2015

6 State of South Carolina Release Worker s Compensation Commission I, hereby authorize the South Carolina Worker s Compensation Commission to provide information in your Worker s Compensation Records concerning me to Strovis Payroll. Applicant s Name-printed Social Security Number Applicant s Signature Date