Welcome to Hospice and Palliative Care of Greensboro

APPLICATION FOR EMPLOYMENT

Date of Application:
Position Applying For:
Date Available:
Salary Required:
What type of position are you interested in?	Full-TimePart-Time
Shift:	DayEveningNight
Last Name:
First Name:
Middle Name:
Maiden:
Present Address (Apt #):
City/State/Zip Code:
	If less than 5 years at present address, please provide previous address.
Previous Address (Apt #):
City/State/Zip Code:
Email Address:
Telephone Number (Home):
Telephone Number (Work):
Telephone Number (Cell):
I prefer to receive calls at:	Home Work Cell
Were you a member of the U.S. Military Services?	Yes No
Branch:	Army Navy Air Force Marines
Date of Discharge:
Reserve Status:	Active Inactive
	Employment History (List most recent employer first).
Company/Agency Name:
Company Address:
Name of Supervisor:
Work Description:
Job Title:
Check One:	Full-Time Part-Time
Dates Employed:
Salary/Hourly Rate:
Reasons for Leaving:
Company/Agency Name:
Company Address:
Name of Supervisor:
Work Description:
Job Title:
Check One:	Full-Time Part-Time
Dates Employed:
Salary/Hourly Rate:
Reasons for Leaving:
Company/Agency Name:
Company Address:
Name of Supervisor:
Work Description:
Job Title:
Check One:	Full-Time Part-Time
Dates Employed:
Salary/Hourly Rate:
Reasons for Leaving:
Have you ever been convicted of any offense (other than minor traffic violation)?	Yes No
Have you ever been convicted of a crime including sex-related or child abuse related offenses?	Yes No
If yes, describe in full, including date(s). Conviction will not necessarily disqualify an applicant from employment.)
Auto Insurance Company:
Have you had more than 3 moving violations or more than one chargeable accident within the past three years?	Yes No
Are you registered in North Carolina?	Yes No
State of Registration:
Year Registration/License Obtained:
Professional:	RN CNA MSW MDIV LPN BSW RD Other
Words Per Minute:
Which of the following are you able to use proficiently?	Calculator Fax Voice Mail Copy Machine Word Excel Power Point Access SQL Database
Education
High School:
Address:
College/University:
Address:
Degree(s):
Graduate /Professional
Address:
Degree(s)
Are you attending school now?	Yes No
Course of Study
Expected Graduation Date
	References (Please give complete and current information below)
Company/Agency
Supervisor:
Phone Number:
Company/Agency:
Supervisor:
Phone Number:
Company/Agency:
Supervisor:
Phone Number:
May we contact your present employer?	Yes No
Are you over the age of eighteen?	Yes No
How did you hear about this particular job vacancy?	Hospice Staff Member Newspaper Professional Journal Website
	I certify that answers given herein are true and complete to the best of my knowledge. I authorize you to conduct a criminal background check. I authorize you to make such investigation and inquiries of my personal employment, motor vehicle records and other job-related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, or persons from all liability in responding to inquiries in connection with my application. In the event of employment, I understand that false or misleading information given on my application or interview(s) may result in termination of my employment. I understand that I am required to abide by the rules and regulations of Hospice at Greensboro, Inc.

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CHURCHILL LECTURE

Event Info
October 5, 2010
Dana Auditorium, Guilford College Campus
Admission - $10

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Hospice and Palliative Care of Greensboro
2500 Summit Avenue • Greensboro, NC 27405
Phone: 336.621.2500
Fax: 336.621.4516

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