Employment with Mountain Hospice
Mountain Hospice is a growing organization and is constantly hiring new employees.
To check for openings in your area, contact:
Lisa Biller, Director of Operations
@ 304-823-3922 ext. 104
***Print This Page For Mountain Hospice Employment Application***
Mountain Hospice, Inc.
1600 Crim Avenue, Belington, WV 26250 (888) 763-7789
Employment Application
Date of Application_________________________
Name__________________________________________________________________
Last First Middle
Address________________________________________________________________
Box Number or Street City State Zip
Home Telephone (_____) ______-________ SS#_____________________________
Position Applied For______________________________________________________
Professional License Number (If Applicable)_________________ State____________
Are you currently employed?_____ If so, by whom?___________________________
Employer Address________________________________________________________
On what date would you be available to begin?_______________________
Check one: Full-time_____ Part-time_____ Temporary_____
Can you assume on-call responsibilities and travel if the job requires? Yes____ No____
Are you under 18 years of age? Yes____ No____
Are you a citizen of the United States? Yes____ No____
Have you ever been convicted of a felony? Yes____ No____
Education
High School___________________________________Graduation Date____________ College______________________________________ Graduation Date____________
Number of years attending college_________Degree(s)__________________________
Major course of study_____________________________________________________
Advance Degrees______________________College/University___________________
Trade, Business or Correspondence School(s)__________________________________
______________________________________________________________________
Subject(s)_________________________Did you complete course(s)?_____yes_____no
Keyboard?________wpm List your working knowledge of office machines?_________
______________________________________________________________________
Other skills/training:______________________________________________________
List other experience, volunteer activities, course, workshops and seminars which may be
applicable to the position applied for:_________________________________________
______________________________________________________________________
Employment Record
Starting with your present or last job, list your work experience.
Employed by:
__________________________________ Dates___________to__________
__________________________________ Phone (_____) _____ - ________
__________________________________
Job Title__________________________________________________________ Supervisor________________________________________________________
Reason for leaving__________________________________________________
Employed by:
__________________________________ Dates___________to__________
__________________________________ Phone (_____) _____ - ________
__________________________________
Job Title__________________________________________________________ Supervisor________________________________________________________
Reason for leaving__________________________________________________
Employed by:
__________________________________ Dates___________to__________
__________________________________ Phone (_____) _____ - ________
__________________________________
Job Title__________________________________________________________ Supervisor________________________________________________________
Reason for leaving__________________________________________________
Employed by:
__________________________________ Dates___________to__________
__________________________________ Phone (_____) _____ - ________
__________________________________
Job Title__________________________________________________________ Supervisor________________________________________________________
Reason for leaving__________________________________________________
If additional space is needed, continue on a separate sheet of paper and attach here.
List any military experience:________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
References
Give name, complete mailing address and telephone number of three references who are
not related to you and are not previous employers.
1. Name____________________________________Phone (_____) _____ - ________
Address____________________________________
___________________________________________
2. Name____________________________________Phone (_____) _____ - ________
Address____________________________________
___________________________________________
3. Name____________________________________Phone (_____) _____ - ________
Address____________________________________
___________________________________________
Physical Record
Do you know of any reason why you cannot perform the essential functions of the job for which you are applying with or without reasonable accommodations? _____yes _____no
If yes, explain___________________________________________________________
______________________________________________________________________
______________________________________________________________________
If yes, what can be done to accommodate for the physical limitations?_______________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Mountain Hospice, Inc.
Application Disclaimer
(Please read and sign)
The facts set forth in my application for employment are true and complete. I understand that if employed, any false statement on this application may result in my immediate dismissal. I further understand that this application is not and is not intended to be a contract of employment, nor does this application obligate Mountain Hospice, Inc., in any way.
Furthermore, I understand that if I am hired, my employment can be terminated with or without cause at any time, at the discretion of either the company or myself.
I hereby give permission to contact the previous employers and character references that I have listed except for the particular employer(s) noted:__________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I understand that by filling out this application that I will not be guaranteed a job and I also understand that this application will only be considered for ninety (90) days unless I contact the Director of Operations for Mountain Hospice, Inc., in writing on a continuous basis that I am still available for employment.
_______________________________ ___________________________________
Date Signature of Applicant
Mountain Hospice, Inc.
Personal Information Release
I, , do hereby authorize Mountain Hospice, Inc., to secure any necessary information from all my employers, references, neighbors, academic, training, or vocational institutions, etc. I understand that background checks will be completed for all new employees. I hereby release all individuals providing said information including but not limited to employers, references, neighbors, academic, training or vocational institutions and Mountain Hospice, Inc., from any and all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications, and my suitability for employment with Mountain Hospice, Inc.
__________________________________________________________________
Date Signature of Applicant
