Employment Application Hospice of West Alabama is an equal opportunity employer. We will not unlawfully discriminate against employees or applicants on the basis of race, color, national origin, ancestry, religious creed or beliefs, age, sex, marital status, medical condition, pregnancy, childbirth or related medical condition, sexual orientation, physical disability, mental disability, citizenship, military status, genetic characteristics, or any other characteristic protected by applicable state or federal law or local ordinance. Step 1 of 6 16% Attach resume and/or referencesName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*If you are hired can you verify your right to work in the United States?*YesNoAre you at least 18 years of age?*YesNoHave you ever been convicted of a felony? (If yes, this is not an automatice disqualification.)*YesNoHave you ever been convicted of Medicare/Medicaid fraud or abuse?*YesNoDo you have a current Alabama drivers license?*YesNoLicense Number: (Include state if other than AL)*List any professional memberships, licenses, certifications, etc.Are you related to anyone who is currently employed at Hospice of West Alabama?*YesNo What position are you applying for?*AdministrationChaplainCounselorHospice AideHousekeepingRegistered NurseSocial WorkerOtherOther:Salary DesiredDays you are available for work Monday Tuesday Wednesday Thursday Friday Saturday Sunday Hours you are available(For example: days, nights, any, etc.)Full-time or part-time?Full-timePart-timeEitherAre you applying for homecare or inpatient?HomecareInpatientEitherDate you can begin Highest level of education completed*(please select)Some High SchoolHigh School Graduate or EquivalentSome CollegeAssociate DegreeBachelor's DegreeGraduate or Professional DegreeOtherPrefer Not to AnswerHighest grade completed9th10th11thPrefer Not to AnswerNumber of years attendedDid you graduate?YesNoYear of graduationCourses/MajorSchool attendedOther: Professional Reference #1 (non-related)*Phone Number*Professional Reference #2 (non-related)Phone NumberProfessional Reference #3 (non-related)Phone Number Employment StatusStart with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, genetic information, or other protected status.Current Employment Status*(please select)Employed Full-TimeEmployed Part-TimeSelf-employedNot employed but looking for workHomemakerRetiredStudentPrefer Not to AnswerEmployerPhone NumberJob TitleSupervisor's Name & Phone NumberReason for leavingFrom (date)To (date)Beginning and Ending SalaryHours worked per weekWork descriptionEmployerPhone NumberJob TitleSupervisor's Name & Phone NumberReason for leavingFrom (date)To (date)Beginning and Ending SalaryHours worked per weekWork descriptionEmployerPhone NumberJob TitleSupervisor's Name & Phone NumberReason for leavingFrom (date)To (date)Beginning and Ending SalaryHours worked per weekWork description I understand and agree to the following:*I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment, as may be necessary, in arriving at an employment decision. I also understand that I may be subject to a criminal background or credit check to verify this information. I understand that I will be required to pass a drug test before a final offer of employment is made. This application for employment shall be considered active for a period of one year. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false, misleading, or omitted information given in my application or interviews may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.* I agree NameThis field is for validation purposes and should be left unchanged.