Career Opportunities

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Seasons Hospice considers applicants for all positions without regard to race, color, sex, national origin, age, marital or veteran status, creed disability, status with regard to public assistance, sexual orientation, or legally protected status. Seasons Hospice maintains employment applications for six months. However, if you have changes in your employment history, address, or phone number, you will need to complete a new application. Each question should be answered fully and accurately. No action can be taken on this application until all questions have been answered fully.

(* Required fields)

Availability
Date of Application*		Position Applying For*
Date available to start*
Desired Schedule*: Full time Part time Supplemental
Desired Shift*: Day Evening Night Weekend
Personal Information
First Name*		Middle Name
Last Name*
Address*
City*	State*	Zip Code*
Day Phone #*		Cell Phone #
Email Address
Are you a citizen of the United States or do you have a valid work permit?* Yes No
Are you 18 years or older?* Yes No
General
How did you hear about this job?
Have you ever been employed here?* Yes No If yes, when?
Have you ever applied here before?* Yes No If yes, when?
Have you ever been convicted of a felony?* Yes No
A conviction record will not necessarily be a bar to employment
Have you had your driver's license suspended or revoked in the last three years?* Yes No
Do you have reliable transportation for the job?* Yes No
Education
Name, Address and Location of School		Highest Grade Completed	Did you Graduate?
High School (or date GED Completed)*:			Yes No
College or University*: Address*: College Major*: Degree*:			Yes No
College or University: Address: College Major: Degree:			Yes No
College or University: Address: College Major: Degree:			Yes No
Additional Education and/or Vocational or Technical Training Information			Did you complete?
School: Address: Courses Taken:			Yes No
School: Address: Courses Taken:			Yes No
School: Address: Courses Taken:			Yes No
Current Professional License or Registration Number
Home Health Aide Certificate: Yes No
Continuing Education Units current to date. Number:
PHN Certification
Advanced Certification
Work History
List names of employers in consecutive order, with most recent listed first. Account for all periods of time including military service and any period of unemployment. If self-employed, give firm name and supply business references. Please list month & year of employment
Name of Current Employer*
Address*
City*	State*	Zip Code*
Phone Number*:
Employed*: From: (Mo/yr) To: (Mo/yr)		Name of Current Supervisor*:
Title*:		Pay*: Start: Final:
Duties*:
Reason for Leaving*: May we contact?* Yes No
Name of Employer
Address
City	State	Zip Code
Phone Number:
Employed: From: (Mo/yr) To: (Mo/yr)		Name of Last Supervisor:
Title:		Pay: Start: Final:
Duties:
Reason for Leaving: May we contact? Yes No
Name of Employer
Address
City	State	Zip Code
Phone Number:
Employed: From: (Mo/yr) To: (Mo/yr)		Name of Last Supervisor:
Title:		Pay: Start: Final:
Duties:
Reason for Leaving: May we contact? Yes No
Name of Employer
Address
City	State	Zip Code
Phone Number:
Employed: From: (Mo/yr) To: (Mo/yr)		Name of Last Supervisor:
Title:		Pay: Start: Final:
Duties:
Reason for Leaving: May we contact? Yes No
Name of Employer
Address
City	State	Zip Code
Phone Number:
Employed: From: (MO/yr) To: (MO/yr)		Name of Last Supervisor:
Title:		Pay: Start: Final:
Duties:
Reason for Leaving: May we contact? Yes No
If any of the above included military service, please indicate the type of discharge. Honorable Dishonorable General
Is any additional information relative to change of name, use of assumed name of nickname necessary to enable us to check your work record? Yes No If so, please explain
Special Skills (Including Volunteer Experience)
References
List five professional references
Name*		Work Phone*
Occupation / Relationship*		Alternate Phone
Address*
Name*		Work Phone*
Occupation / Relationship*		Alternate Phone
Address*
Name*		Work Phone*
Occupation / Relationship*		Alternate Phone
Address*
Name*		Work Phone*
Occupation / Relationship*		Alternate Phone
Address
Name*		Work Phone*
Occupation / Relationship*		Alternate Phone
Address*
Affidavit
I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever. I agree that the company shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me in this questionnaire. I also authorize the companies, schools, or persons named above to give any information regarding my employment, character and qualifications. I hereby release said companies, schools or persons from all liability for any damage for issuing this information. I expressly waive all provisions of law prohibiting any physician, person, hospital or other institution that has or may hereafter attend of furnish me with treatment from disclosing to the company any knowledge or information thereby acquired. I understand that any misleading or incorrect statements may render this application void, and if employed, would be cause for termination. I understand that there is no express or implied contract of employment and that if employed I have been hired at the will of the employer and that my employment may be terminated at will, at any time; and with or without cause. The employer's only obligation being to pay salary or wages due and owing at the time of the termination. I authorize the company to deduct from my final paycheck(s) all monies due and owing to the company.
Signature*			Date *