Online Employment Application
APPLICATION FOR EMPLOYMENT
Hospice of Davidson County
200 Hospice Way
Lexington, NC 27292
1-336-475-5444
We are an Equal Opportunity Employer. Federal and state laws prohibit against discrimination on the basis of age, race, color, gender, national origin, religion, and disability.
Applications are kept active for one year. After one year applications are archived, and you will need to
fill out a new application. Please complete all fields.
Last Name:
First Name:
Middle/Maiden Name:
Address:
City:
State
Zip::
Home Phone:
Business Phone:
Can you submit proof of legal employment authorizations and identity?
Social Security Number
Email Address
Do you have a valid driver’s license?
If yes, please list drivers license number
State Issued
Positions applied for
1)
2)
Salary Requested
Hours preferred
Have you ever filled out an application with Hospice of Davidson County before?
If yes, when
Have you ever been employed with Hospice of Davidson County?
If yes, when
Do you have relatives working for Hospice of Davidson County?
If yes, please list
Have you ever been convicted of any unlawful offenses, other than a minor traffic violation?
If yes, please explain in detail.
High School
College or University
Graduate/Professional
Years completed?
Address
Address
Address
Highest grade completed
Years completed?
Did you graduate?
Did you receive a degree?
Did you receive a degree?
Are you attending school now?
Course of Study
Expected Graduation Date
Military Service
Were you a member of the U.S. Military Service?
Reserve Status
Date of Discharge
Professional
Do you know a foreign language?
If yes, please list foreign language
Do you speak and write the foreign language fluently?
Technical
Which of the following are you able to use proficiently?
wpm
Other Skills
EMPLOYMENT HISTORY (List present/most recent employer first)
Company/Agency Name
Address
Name of Supervisor
Phone
Check One:
Dates employed
Salary/hourly Rate
Reason for Leaving
Job Title
Zip:
Education
Duties
May we contact your employer?
To:
Company/Agency Name
Address
Name of Supervisor
Phone
Job Title
Duties
May we contact your employer?
Check One:
Dates employed
Salary/hourly Rate
Reason for Leaving
To:
Company/Agency Name
Address
Name of Supervisor
Phone
Job Title
May we contact your employer?
Duties
Check One:
Dates employed
Salary/hourly Rate
Reason for Leaving
To:
Company/Agency Name
Address
Name of Supervisor
Phone
Job Title
Duties
May we contact your employer?
Check One:
Dates employed
Salary/hourly Rate
Reason for Leaving
To:
References (3 work references and 1 personal)
Company
Supervisor
Address
Phone
Company
Supervisor
Address
Phone
Company
Supervisor
Address
Phone
Company
Supervisor
Address
Phone
Please indicate your referral source
Employee, website, newspaper, job link, walk-in, other.
READ AGREEMENT IN FULL
I certify that the answers given by me in the foregoing questions are true and correct without consequential omissions of any kind whatsoever. I agree that my employer shall not be liable in any respect if my employment is terminated because of falsifying statements, answers, or omissions made by me in this application. If I am extended an offer of employment with Hospice of Davidson County, I understand I will be required to successfully pass a pre-employment screening.
I authorize Hospice of Davidson County to conduct or investigate the following pre-employment screening and test which may include but not limited to: drug test, criminal background check, motor vehicle record, education verification, employment history, credit report and personal history. I hereby release my employers, schools, or persons named above from all liability for any damages, both legal and otherwise, for issuing this information.
I fully understand that if I fail any pre-employment screening or test, the offer of employment will be withdrawn.
If accepted for employment, I hereby agree to abide by the rules and policies of Hospice of Davidson County. Further, I understand that any employment is not for a stated period of time and may be terminated with or without cause, at any time, at the option of either my employer or myself.
This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the American with Disabilities Act (ADA) and other relevant federal and state laws.
Name
Date
Hospice of Davidson County is a Drug Free and Smoke Free Facility
Please email Resume
in Word format to Joan Blevins
