Apply Today Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Number of Years at Address Phone * (###) ### #### Social Security Number Driver's License (State/Number) * Emergency Contact Who should be contacted in case of an emergency? Name First Name Last Name Emergency Contact Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Phone (###) ### #### Employment Position Applying for Seeking Full/Part Time? Full Time Part Time Salary Desired? (Hourly) Who Referred you to our company? Current Employee Google Social Media Recruiter Family Friend Other If Applicable, please Specify: Have you previously applied to work with Align Hospice? No Yes If yes, when? Are you at least 18 years old? Yes No Are you willing to work any shift, including nights and weekends? Yes No If no, please state any limitations: Are you available to work overtime? Yes No If offered employment, when would you be available to work? MM DD YYYY If hired, are you able to submit proof that you are legally eligible for employment in the United States? Yes No Are you able to perform the essential functions of the job position you seek with/without reasonable accommodation? Yes No What reasonable accommodation, if any, would you request? Employment History List your current or most recent employment first. Please list all jobs held, beginning with the most recent, and list and explain any gaps in employment Employer #1 Supervisor Name First Name Last Name Employer Address Address 1 Address 2 City State/Province Zip/Postal Code Country Job Duties Reason for Leaving Dates of Employment Employer #2 Supervisor Name First Name Last Name Employer Address Address 1 Address 2 City State/Province Zip/Postal Code Country Job Duties Reason for Leaving Dates of Employment LinkedIn / Website http:// Education and Training College / University Name College / University Address Address 1 Address 2 City State/Province Zip/Postal Code Country Did you receive a degree? Yes No If yes, degree(s) received High School / GED Name High School Address Address 1 Address 2 City State/Province Zip/Postal Code Country Did you receive a degree? Yes No Please list any other training (graduate, technical, vocational) Please indicate any current professional licenses or certifications that you hold Awards, Honors, Special Achievements: References Please list any THREE non-relatives who would be willing to provide a reference for you. Include: First & Last Name Address Phone Number Relationship Reference #1 Reference #2 Reference #3 Additional Information Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer Certification * I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination. I authorize Align Hospice Care, Inc. to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to communicate pertinent information. I authorize those persons designated as references to communicate information fully and freely regarding my previous employment and education. If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its Administrator or hiring manager, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Align Hospice Care, Inc., except in a specific written contract employment signed on behalf of the organization by its Administrator or hiring manager, has the power to alter or vary the voluntary nature of the employment relationship. I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS Applicant Full NAme * By typing my name below, I give consent to accept my typed name as an electronic signature. Thank you for your application.Someone on our team will review your application, and if we think you’d be a great fit, we’ll be reaching out to you. We’re glad you want to be a part of Align Hospice Care. Best of luck!Align Hospice Care
