Employment Application



* = Required

Application Information

First Name *
Last Name *
M.I.
Date

Street Address *
Apt/Unit #

City *
State *
ZIP *

Phone *
Email *

Date Available
Desired Salary
Position Applying For

Are you a citizen of the United States? *

If no, are you authorized to work in the U.S.?

Have you ever worked for this company? *


If yes, when?

Have you ever been convicted of a felony? *

If yes, please explain:

Education

High School Name
Address

City
State
ZIP

From
To
Did You Graduate?

Diploma

College Name
Address

City
State
ZIP

From
To
Did You Graduate?

Degree

Other
Address

City
State
ZIP

From
To
Did You Graduate?

Degree

Previous Employment

Company
Phone

Address
City
State
ZIP

Supervisor
Job Title
Starting Salary
Ending Salary

Responsibilities:

From
To
Reason For Leaving

May we contact your Supervisor for a reference?

Company
Phone

Address
City
State
ZIP

Supervisor
Job Title
Starting Salary
Ending Salary

Responsibilities:

From
To
Reason For Leaving

May we contact your Supervisor for a reference?

Company
Phone

Address
City
State
ZIP

Supervisor
Job Title
Starting Salary
Ending Salary

Responsibilities:

From
To
Reason For Leaving

May we contact your Supervisor for a reference?

Disclaimer and Signature

*

Professional References

Name
Company
Phone

Address
City
State
ZIP

Name
Company
Phone

Address
City
State
ZIP

Name
Company
Phone

Address
City
State
ZIP

I have applied for work at Hospice of Lenawee. I hereby authorize Hospice of Lenawee to request, and also authorize emy above listed references to answer all questions that may be asked, and give all information that may be necessary in connection with this application or concerning me or my work habits, character or skills. I further agree to hold Hospice of Lenawee and my above listed references harmless from any and all liability from the release of the information contained on this form. I understand that the information shared will be held in the strictest confidence by both parties.

*

Date