Application for Employment Take a moment to fill out and submit the information below or email your prepared resume to info@silvercresthospice.com or

Today's Date - *

Name - *

First

Middle

Last

Contact Number - *

Email - *

Last 4 Digits of your Social Security Number - *

Address - *

Are you legally authorized to work in the United States? *

• Yes
• No

Position applying for - *

How were you referred to Silver Crest Hospice?

Education - *High SchoolCollegeGraduate School

School Name - *

Number of years completed - *

Licensing Information - Clinical / Health Care Applicants Only

Work Experience ( Present / Most Recent ) - *

Date From - *

Company Address - *

Job Title - *

Job Duties - *

Supervisor Information - *

Reason for Leaving - *

References - *

Have you ever been convicted of a Felony or Misdemeanor Crime? *

• Yes
• No

Have you ever been Bonded? *

• Yes
• No

If Yes, Explain -

Have you even been refused a bond? *

• Yes
• No

If Yes, Explain -

Are you bound by a Non-Competition Agreement to your Current or Previous Employer? *

• Yes
• No

I understand that submitting this application is the first step in the application process and is not a guarantee of employment - *

• Yes
• No

I certify that the information in this application is accurate, current, and complete. I understand that misstatements or omissions may result in disqualification from further consideration or termination of employment. - *

• Yes
• No

I authorize Silver Crest Hospice© to conduct investigations in which information may be obtained through personal interviews with business associates, personal acquaintances, financial sources, or other third parties regarding my employment history, credentials, character and credit background, and to obtain any relevant information (including a criminal background check and consumer report) needed to make an employment evaluation during the course of the interview process for local, state, federal, contractual, or accreditation audit purposes. I also authorize Silver Crest Hospice© to disclose any of my performance appraisals, disciplinary records, or skills tests for the same purposes as above. I release Silver Crest Hospice© from all liability for any damages from the disclosure of this information. - *

• Yes
• No

I understand that I may be subject to pre-employment drug testing or a drug test where a reasonable suspicion exists, or where warranted by circumstances and workplace conditions. - *

• Yes
• No

I understand that nothing contained in this application or in granting of an interview creates an employment contract between Silver Crest Hospice© and myself for either employment of or the providing of any benefit. No promises regarding employment have been made to me. If an employment relationship is established, I understand that my employment will be "at will", that I will have the right to terminate my employment at any time, and that Silver Crest Hospice© will retain a similar right to terminate my employment at any time, with or without cause. - *

• Yes
• No

I understand that this application is a continuous document and should any of the information which I gave change, I am obligated to notify Silver Crest Hospice© immediately. I understand that should I become employed, my work assignments, schedules, and work locations are subject to change according to the needs of the business and the clients of Silver Crest. - *

• Yes
• No

I authorize my electronic signature below and agree that the information in this application is true and accurate to the best of my knowledge. - *

Submit