Employment Application | Hospice of the North Coast

Employment Application

Hospice of the North Coast does not discriminate against any person on the basis of age, race, color, creed, national origin, disability, sexual orientation, or ability to pay, either in admission, treatment, or participation in its programs, services and activities, or in employment. For further information about this policy, contact the executive director (760) 431-4100/TDD# 1-800-877-8339.

Last Name
First Name
Middle Name
Current Street Address
City, State, Zip Code
Contact Number
Social Security #
State name and relationship of any relatives in our employ
Referred by
Desired Position
Date you can start
Desired Salary (per year)
Are you currently employed	Yes No
May we contact your current employer	Yes No
If yes, contact name and position
Employer Address
City, State, Zip Code
Name of High School
Address
City, State, Zip Code
Graduated	Yes No
Name of College
Address
City, State, Zip Code
Degree Received
Other Schooling (specify)
Address
City, State, Zip Code
Degree or Certification Received
Subject of special study or research work
Special training
Activities (civic, athletic, etc.)
Former Employer (1)
Address
City, State, Zip Code
From date
To date
Salary (per year)
Position
Reason for leaving
Former Employer (2)
Address
City, State, Zip Code
From date
To date
Salary (per year)
Position
Reason for leaving
Former Employer (3)
Address
City, State, Zip Code
From date
To date
Salary (per year)
Position
Reason for leaving
Former Employer (4)
Address
City, State, Zip Code
From date
To date
Salary (per year)
Position
Reason for leaving
Reference 1 (non-relative whom you have known at least one year)
Address
City, State, Zip Code
Contact Number
Years Acquainted
Reference 2 (non-relative whom you have known at least one year)
Address
City, State, Zip Code
Contact Number
Years Acquainted
Reference 3 (non-relative whom you have known at least one year)
Address
City, State, Zip Code
Contact Number
Years Acquainted
If you hold a license or certification for nursing or other professional services, has it ever been revoked for any reason	Yes No
If yes, please explain
Have you ever been convicted of a felony	Yes No
If yes, please explain
Name of contact person (in case of emergency)
Address
City, State, Zip Code
Contact Number
I attest that all information in this application is true	Yes No
I authorize investigation of all statements contained in this application	Yes No
I understand that misrepresentation or omission of facts requested is cause for dismissal	Yes No
Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice	Yes No
I agree, in typing my First and Last name (to the right of this statement) Hospice of the North Coast may use this as my electronic signature
Month
Day
Year

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