Application - Oregon Coast Home Health Care and Hospice

PERSONAL INFORMATION

Name *

First

Last

Phone *

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Employment Position Position(s) applying for: *

How did you hear about this position?

On what date can you start working if you are hired? *

Do you have reliable transportation to and from work? *

Are you a U.S. citizen or approved to work in the United States? *

Yes

What document can you provide as proof of citizenship or legal status?

Do you have any condition which would require job accommodations? *

Yes
No

If yes, please describe accommodations required. *

I understand that Advanced will conduct a background check prior to making a an offer for employement. Advanced Home Health and Hospice will obtain aurhtorization from you prior to conducting this background check. *

Yes
No

Job Skills/Qualifications

Please list the skills and qualifications you possess for the position for which you are applying. (Note: Advanced Home Health and Hospice NW of Wenatchee complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. )

HIGH SCHOOL

High School

City/State (copy)

Year Graduated

Degree Earned

COLLEGE

College/University

City/State

Year Graduated

Degree Earned

VOCATIONAL OR SPECIALIZED SCHOOLING

Vocational /Specialized

City/State

Year Graduated

Degree Earned

PREVIOUS EMPLOYMENT 1

Job Title

Employer Address

Supervisor Name

Employer City/State

Employer Telephone

Employer Zip

Dates Employed

Reason for leaving

PREVIOUS EMPLOYMENT 2

Job Title

Employer Address

Supervisor Name

Employer City/State

Employer Telephone

Employer Zip

Dates Employed

Reason for leaving

Job Title

Employer Address

Supervisor Name

Employer City/State

Employer Telephone

Employer Zip

Dates Employed

Reason for leaving

REFERENCES

Reference 1

Reference 2

Contact Information

AT-WILL EMPLOYMENT The relationship between you and the Advanced Home Health and Hospice NW of Wenatchee is referred to as "employment at will."This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Advanced Home Health and Hospice NW of Wenatchee. No representative of Advanced Home Health and Hospice NW of Wenatchee has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice- President/Chief Operations Officer or the Company's President.

Signature

Clear Signature