Job Application

* Required Field

APPLICANT INFORMATION

Date:

Name:

Address:

Phone:

E-mail*:

Are you 18 Years of age or older?YesNo

Are you legally eligible to be employed in the United States?YesNo

Have you been charged or convicted of a felony/ misdemeanor or know of any other reason you might not pass the mandatory criminal background check? (According to the MN Department of Human Services all potential candidates must pass a criminal background check before employment may be offered)
YesNo

EMPLOYMENT DESIRED

Position desired*:

Desired hours per week*:

Date available to begin work:

Have you ever worked with Serenity Hospice Homes? YesNo

Were you referred by a PCA or a client?YesNo

Are you presently working with another home health care company?YesNo

Are you applying to work with a specific client?

Are you currently employed?YesNo

If yes may we contact your employer?YesNo

EMPLOYMENT HISTORY

(PLEASE START WITH YOUR RECENT EMPLOYER)

Company Name: *

Supervisor’s name: *

Company address: *

Telephone: *

Position and Duties: *

Dates of Employment:

From *

to*

Starting pay: *

Ending Pay:*

Reason for Leaving: *

Company Name: *

Supervisor’s name: *

Company address: *

Telephone: *

Position and Duties: *

Dates of Employment:

From *

to*

Starting pay: *

Ending Pay:*

Reason for Leaving: *

Company Name: *

Supervisor’s name: *

Company address: *

Telephone: *

Position and Duties: *

Dates of Employment:

From *

to*

Starting pay: *

Ending Pay:*

Reason for Leaving: *

EDUCATION HISTORY

Do you have any other experience, training, qualifications or skills which you feel make you especially suited to work for Serenity Hospice Homes, Inc?
If so, please explain

EMPLOYMENT HISTORY

(PLEASE START WITH YOUR RECENT EMPLOYER)

Please list below three professional references. Professional references are individuals who can attest to your work performance in a professional or academic setting such as a direct supervisor, colleague, academic advisor or a professor.

Name: *

Occupation: *

Address: *

Telephone: *

Number of years acquainted: *

Name: *

Occupation: *

Address: *

Telephone: *

Number of years acquainted: *

Name: *

Occupation: *

Address: *

Telephone: *

Number of years acquainted: *

PLEASE READ CAREFULLY AND SIGN TITLE

Serenity Hospice Homes is committed to providing a safe, healthy, and productive work environment. We promote a drug, alcohol, and smoke-free environment that encourages our employees to maintain healthy lifestyles so as to provide the best care possible to our patients. We reserve the right to test for the presence of alcohol, illegal drugs, and unauthorized prescription drugs in situations where a reasonable suspicion of usage exits. We also promote a work environment free from discrimination, harassment, and violence.

Print Name:

Date:

Agreement and Application Release

I understand that the information on this Application has been requested for the purpose of evaluating my qualifications for employment and that this document, or any item discussed regarding employment, does not constitute a contract or promise of employment. I affirm that the information provided in my application, resume, and interview is true and correct to the best of my knowledge.

I authorized Serenity Hospice Homes to investigate my background including all the information contained in my application and information I provided in the interview. I understand that misrepresentation or omission of information in connection with my application, resume, and/or interview will be sufficient cause. in and of itself, for rejection or dismissal whenever discovered. I understand and agree that any offer of employment is dependent upon my satisfactory completion of Serenity Hospice Homes Pre-employment investigation, which may include but is not limited to a pre placement health assessment; verification of current work authorization in the United States: criminal history check; work-history verification; reference checks, and any other investigation required by the position in which I am applying for or as mandated by local, state, or federal laws, I waive and release any and all claims, including by not limited to claims of defamation, libel, and slander, that I may have against any such individual or company as a result of their compliance with Serenity Hospice Homes request for information.

I authorize all educational institutions I have attended to provide Serenity Hospice Homes with all information which it seeks related to the dates of my attendance, the degrees I have named, the courses I have taken, my grades, and related matters. I waive and release any and all claims I may have against these institutions as a result of their compliance with V- Care request for information.

By Signing below, I am affirming my understanding and acknowledgement of support in all items addressed in this document. I further understand that if I am hired by Serenity Hospice Homes, my employment will be "at will," which means that either Serenity Hospice Homes (or designee), and that no representative of Serenity Hospice Homes has the authority to make any oral promise to me concerning my employment.

Print Name:

Date: