Be Part of Our Team of Hospice Care Professionals

Present Address

EMPLOYMENT DESIRED

PERSONAL INFORMATION

(Note: We may refuse to hire relatives of present employees if doing so could result in actual potential problems in supervision, security, safety, or morale, or if doing so could create conflicts of interest.)

EDUCATION, TRAINING AND EXPERIENCE

High School

College / University

Other/Vocational/Business

Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying

COMPUTER SKILLS

(Check appropriate boxes. Include software titles and years of experience.)

REFERENCES

– List below three persons, not related to you, who have knowledge of your work performance within the last five years.

EMPLOYMENT HISTORY

List below all present and past employment starting with your most recent employer. Account for all periods of unemployment. You must complete this section even if attaching a resume.

Please Read Carefully, Initial Each Paragraph and Sign /Date Below

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
I hereby authorize Reliance Hospice to investigate my references, work record, education, and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to Reliance Hospice any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release Reliance Hospice, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
I understand that Reliance Hospice may require applicants for employment to take a urinalysis for drug and alcohol screening as part of the selection process, and that any offer of employment with Reliance Hospice is contingent upon the results of these tests being satisfactory. I understand that if I am employed with Reliance Hospice, it may require that I submit to a drug and/or alcohol screen if I am involved in an on-the-job accident or if Reliance Hospice has reasonable suspicion that I am under the influence of drugs or alcohol; and I hereby authorize the release of these drug screen results to Reliance Hospice.
I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and Reliance Hospice. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or Reliance Hospice, and that no promises or representations contrary to the foregoing are binding on Reliance Hospice unless made in writing and signed by me and the Reliance Hospice designated representative.
In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

We Are An Equal Employment Opportunity Employer