Personal Data

Emergency Contact Information

Job Information

Position (Job Class) Applying for:

Work Experience/Skills

Please list the number of years you have experience in each area (min 1 year exp.) and are clinically competent to work:

Previous Facility Types Worked: Check All That Apply –

Language Skills: Other than English, please check any other languages you speak –

Check the type of assignment you are available for:

Check the days of the week you are available to work:

Has your professional license ever been suspended, revoked or under investigation?

Certifications: Check all applicable certifications and enter expiration date:

Work Experience:List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment. Attach additional sheet(s) if necessary.

Additional Information:

Are you legally authorized to work in the USA?

Have you ever been convicted of a felony?

Can you pass a pre-employment drug test?

How were you referred to RIVER HOSPICE?

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I certify that answers given above are true and complete to the best of my knowledge. I understand that false information in my application or interview may lead to termination. All medical care provided by me RIVER HOSPICE Patients is subject to CMS and State survey and I am responsible for any action taken against RIVER HOSPICE and all discrepancy found in my care and paper work. I authorize investigation of all references and statements as may be necessary to reach an employment decision. I understand that employment is conditional upon successful completion of a health assessment.I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment.

I give RIVER HOSPICE permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by RIVER HOSPICE with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, RIVER HOSPICE may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release RIVER HOSPICE, its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

In consideration of my employment and of my being considered for employment by RIVER HOSPICE, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either RIVER HOSPICE or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of RIVER HOSPICE, at any time, can constitute a contract of employment. No representative or agent of RIVER HOSPICE, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.

DOCUMENT CHECKLIST

Please provide the following documents for employment: