Employment Application Please fill this entire form to the best of your ability. Personal Information Contact Information Current Address I am a U.S. Citizen or authorized to work in the United States on an unrestricted basis: Yes No If applicable, please list your visa number, visa type, and expiration: Have you ever served in the U.S. Military? Yes No Emergency Contact POSITION INFORMATION Employment type: Full time Part time Per diem Can work weekends? Yes No Willing to travel? Yes No STATEMENT OF COMPANY INTEGRITY ZIBA HOSPICE is committed to conducting business affairs in a responsible, ethical, and professional manner in compliance with applicable laws and regulations. Your responses to the following questions will help us achieves these objectives. Are you now or have ever been investigated by any governmental agency for health care fraud, abuse or other alleged offenses? Yes No Are you excluded from participating in any government programs such as Medicaid and Medicate due to fraud and /or abuse? Yes No Have you ever been convicted of a felony? Yes No Have you ever been fired or asked to resign from a job? Yes No EMPLOYMENT HISTORY Recent or Relevant Experience (attach resume for additional employers) May we contact your supervisor? Yes No EDUCATION High School Graduated? Yes No GED Other College or University Graduated? Yes No In Progress Other Education Graduated? Yes No In Progress LICENSES AND CERTIFICATES SKILLS Please describe any skills in the following areas Declaration I hereby certify that the statements made on this application are true and correct to the best of my knowledge. I understand that, by submitting this application I authorize inquiries to be made concerning my employment, education, character, and public records for the purpose of determining my suitability as an employee. I understand that if I am hired, employment with this company is "at will", which means that either the company or I can terminate my employment for any reason not prohibited by state or federal law. Attach Resume/CV (pdf, doc, or rtf; maximum file size: 1 MB)
