Hospice of Davidson County

200 Hospice Way

Lexington, NC 27292

(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 on file for 90 days. After 90 days, applications are archived and you will need to complete a new application. Please complete all fields.

Employment Application

Title

First Name *

Middle Initial

Last Name *

Suffix

Address *

Address Line 2

City *

State *

Zipcode *

Work Information

How did you hear about Hospice of Davidson County? (Friend, Google Ad, Facebook, Indeed, Agency Website, Other) *

Referred by *

Can you submit proof of legal employment authorizations and identity? *

Yes

No

Email Address *

Preferred Phone Number *

Do you have a valid NC driver's license? *

Yes

No

(1) Position applied for *

(2) Position applied for

Shift preference - please select all that apply *

Full Time

Part Time

PRN

Weekends-Only

Hours preferred

AM

PM

Salary requested *

Have you ever filled out an application with Hospice of Davidson County before?

Yes

No

Have you ever been employed with Hospice of Davidson County before? *

Yes

No

If yes, please list the previous position(s) held

If yes, please list the previous position(s) held

Do you have relatives working with Hospice of Davidson County? If yes, please list.

Have you ever been convicted of any unlawful offenses, other than minor traffic violations? *

Yes

No

If yes, please explain in detail

Education

High School or GED *

City, State

Did you graduate?

Yes

No

Community College, College or University *

City, State

Did you receive a degree or certificate? *

Yes

No

If so, what type of degree did you receive?

Graduate/Professional College or University

City, State

Did you receive a degree or certificate?

Yes

No

If so, what type of degree did you receive?

Are you attending school now?

Yes

No

Course of Study

Military Service

Were you a member of the U.S. Military Service?

Yes

No

Reserve status

Active

Inactive

Date of Discharge

Professional

License/Certificate Number

Are you fluent in a foreign language?

Yes

No

If yes, please list language

Technical

Typing Speed (words per minute)

Other Skills

Employment History

Company/Agency Name

City/State

Phone

Supervisor/Manager

Job Title

From (MM/YYYY)

To (MM/YYYY)

Check one

Full Time

Part Time

Salary/Hourly rate

Duties

Reason for leaving

May we contact your employer?

Yes

No

Company/Agency Name

City/State

Phone

Supervisor/Manager

Job Title

From (MM/YYYY)

To (MM/YYYY)

Check one

Full Time

Part Time

Salary/Hourly rate

Duties

Reason for leaving

May we contact your employer?

Yes

No

Company/Agency Name

City/State

Phone

Supervisor/Manager

Job Title

From (MM/YYYY)

To (MM/YYYY)

Check one

Full Time

Part Time

Salary/Hourly rate

Duties

Reason for leaving

May we contact your employer?

Yes

No

References

Name

Company

Phone

Name

Company

Phone

Name

Company

Phone

Please submit a copy of your resume. Files must be uploaded as pdf documents.

Agreement

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 be limited to: drug test, criminal background check, motor vehicle record, education vertification, 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 Americans with Disabilities Act (ADA) and other relevant federal and state laws.

Signature, using full legal name *

Date *