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   Specializing in end-of-life care since 1978



 

 

 

 

 

 

 

 


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or Contact Us

Online Employment Application


An asterisk indicates the informatin is required for sending.

Personal
Application Date:*
First Name:*
Middle Name:
Last Name:*
Street Address:*
City:*
State:*
Zip:*
Home Phone:*
Business Phone:
Email Address:
Position Desired:*
Pay Expected:
Are you legally eligible for employment in the United States?* Yes No
When Available?
Special Training/Skills (Languages, machine operation, etc.):
   
Education  
School Graduate College Business/ Trade/ Technical High School
Name & Location of School  
Course of Study  
# Yrs. Completed  
Graduate? Yes  No Yes  No Yes  No Yes  No  
Degree/ Diploma  


Prospective employees will receive consideration without discrimination because of race, creed, sex, age, national origin, handicap or veteran status.


The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex or national origin. Federal law also prohibits discrimination based on age, citizenship and disability. The laws of most States also prohibit some or all of the above types of discrimination as well as some additional types such as discrimination based upon ancestry, marital status and sexual preference.
   
Employment  
1.  
Company Name: Phone:
Street Address: Employed from:
(Month/Year) to
(Month/Year)
City: State:  
Zip: 		Wage: Starting
          - Ending
Supervisor’s Name:
Job Title & Description:
 Reason for Leaving:
2.  
Company Name: Phone:
Street Address: Employed from:
(Month/Year) to
(Month/Year)
City: State:
Zip: 		Wage: Starting
          - Ending
Supervisor’s Name:
Job Title & Description:
 Reason for Leaving:
3.  
Company Name: Phone:
Street Address: Employed from:
(Month/Year) to
(Month/Year)
City: State:

Zip: 		Wage: Starting
          - Ending
Supervisor’s Name:
Job Title & Description:
 Reason for Leaving:
4.  
Company Name: Phone:
Street Address: Employed from:
(Month/Year) to
(Month/Year)
City: State:

Zip: 		Wage: Starting

          - Ending
Supervisor’s Name:
Job Title & Description:
 Reason for Leaving:
   
We may contact the employers you listed unless you indicate those y ou do not want us to contact.
Please Do Not Contact:  
Employer(s) Number:
Reason:
   
Personal References  
Please list three references. Include a mailing address for each reference.
(At least one reference should be a past supervisor)
1.  
Name:
Address:
Phone:
   
2.  
Name:
Address:
Phone:
   
3.  
Name:
Address:
Phone:
   
Professional/Civic Organizations
(Exclude those which may disclose your race, color, religion or national origin.)
 
   
About this Job  
Why do you feel that you are qualified for this job?
   
Have you ever been convicted of a felony?* Yes No
   
Signature  
  • Medicare/Medicaid Fraud – I understand that Seacoast Hospice uses the Medicare Cumulative Sanction Report (CSR) to report on convictions of certain health care related offenses.
  • 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.
  • I understand that Seacoast Hospice will be conducting a criminal background check, and that continued employment is contingent on the results of this check.
  • 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 of the agency so I may obtain from them the nature and substance of the information contained in the report.
  Initial for signature:*


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