Employment Application

* = required
 Personal Data
Name
First:*
Last:*
MI:
Social Security # *
Address *
City *
State: *
Zip *
Home Phone *
E-mail Address *
Are you 18 years or older? Yes No *

 Employment Desired
Position *
Date you can start *
Desired salary *
Have you ever applied to
Hospice of Charleston before?  
Yes No *
if yes, when?
Who referred you to us?

 Education
 School   Name & Location   # Years Completed   Degree Received/Major Field 
High
College
Graduate School
Other

 Other
Subjects of special study, research work or special skills:
List any job related professional memberships:
Are you able to perform the essential functions of the job with or without a reasonable accommodation? Yes No *


 References
Employment (start with most recent)
1. Name
Address
Phone Name of Supervisor
Job Title Pay Rate
Dates of Employment  From: To:
Reason for Leaving


2. Name
Address
Phone Name of Supervisor
Job Title Pay Rate
Dates of Employment  From: To:
Reason for Leaving


3. Name
Address
Phone Name of Supervisor
Job Title Pay Rate
Dates of Employment  From: To:
Reason for Leaving


4. Name
Address
Phone Name of Supervisor
Job Title Pay Rate
Dates of Employment  From: To:
Reason for Leaving


Are you employed now? Yes No
If so, may we inquire your present employer? Yes No

List 3 Personal References (not related to you, who have known you for at least a year)
Name: Address: Phone #:
Name: Address: Phone #:
Name: Address: Phone #:


"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. I understand and agree that, if hired, employment is for no definite period and may regardless of the date of payment of my wages, be terminated at any time without any prior notice."
Your name: * Date: *