Employment Application

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Beth Hoffmann answers your hospice questions

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Q: When I make the choice to start hospice service, does my insurance company direct which hospice I use?

A: No. Patients have the right to choose their hospice provider. Physicians or other caregivers may recommend a hospice, but patient choice must be honored. When looking for a hospice provider, it's important to know all your options.

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Employment Application

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and / or interview process should notify a representative of the Human Resources Department.

Position(s) applied for: Date of application:

Name: Social Security #:

Address:

Telephone #: Mobile/Beeper/Other #: E-Mail:

Referral Source (How did you hear about us?):

If you are under 18, can you furnish a work permit? Yes No

If no, please explain:

Have you ever been employed here before? Yes No

If yes, please give dates and position:

Are you related to any current or former Hoffmann Hospices employees? Yes No

If yes, give names:

Are you legally eligible for employment in this country? Yes No

Date available for work: What is your desired salary range?

Type of employment desired? Full-Time Part-Time Temporary Seasonal Educational Co-Op

Driver's License number if driving may be required in the position for which you are applying:

Driver's License State:

Professional License (if any):

License Type: RN LVN CHHA None

Answering yes to the following questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

Have you ever pled guilty, no contest to, or been convicted of a crime? Yes No

If yes please provide date(s) and details:

Employment History

Starting with your most recent employer, provide the following information.

Employer 1

Employer: Telephone #:

Street address: City: State:

Starting job title/final job title:

Immediate supervisor and title (for mos recent position held):

May we contact for reference? Yes No Later

Summarize the type of work performed and job responsibilities:

What did you like most about the position?

What did you like least about the position?

Dates Employed: to

Compensation (Starting)

Salary Hourly $ Per

Commission/Bonus/Other Compensation:

Compensation (Final)

Salary Hourly $ Per

Commission/Bonus/Other Compensation:

Employer 2

Employer: Telephone #:

Street address: City: State:

Starting job title/final job title:

Immediate supervisor and title (for mos recent position held):

May we contact for reference? Yes No Later

Summarize the type of work performed and job responsibilities:

What did you like most about the position?

What did you like least about the position?

Dates Employed: to

Compensation (Starting)

Salary Hourly $ Per

Commission/Bonus/Other Compensation:

Compensation (Final)

Salary Hourly $ Per

Commission/Bonus/Other Compensation:

Employer 3

Employer: Telephone #:

Street address: City: State:

Starting job title/final job title:

Immediate supervisor and title (for mos recent position held):

May we contact for reference? Yes No Later

Summarize the type of work performed and job responsibilities:

What did you like most about the position?

What did you like least about the position?

Dates Employed: to

Compensation (Starting)

Salary Hourly $ Per

Commission/Bonus/Other Compensation:

Compensation (Final)

Salary Hourly $ Per

Commission/Bonus/Other Compensation:

You are about to submit personal information over the internet. While Hoffmann Hospice will make every reasonable attempt to ensure that your information is kept safe, please understand that there is an inherent risk to exchanging confidential information by any means (electronic or otherwise). By submitting this form you acknowledge that you understand and accept this risk.

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