Best Home Health and Hospice Service

(408) 755-1215
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Employment Application

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Our policy is to provide equal employment opportunity to all qualified persons without regard to race, creed, color, religious belief, sex, age, national origin, ancestry, physical or mental disability, or veteran status.

    Date:

    First name* :

    Middle name:

    Last name:

    Street Address:

    City* :

    State* :

    ZIP:

    Telephone* :

    Social Security #:

    Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? (You may be required to provide documentation.)* :
    YesNo

    Are you looking for full-time employment?* :
    YesNo

    If no, what hours are you available?* :

    Are you willing to work the swing shift?* :
    YesNo

    Are you willing to work the graveyard?* :
    YesNo

    Have you ever been convicted of a felony? (This will not necessarily affect your application.)* :
    YesNo

    If yes, please describe the conditions* :

    Employment Desired

    Position applied for* :

    How did you hear of this opening?* :

    Have you ever applied for employment here?* :
    YesNo

    When?* :

    Where?* :

    Have you ever been employed by this company?* :
    YesNo

    When?* :

    Where?* :

    Are you presently employed?* :
    YesNo

    May we contact your present employer?* :
    YesNo

    Are you available for full-time work?* :
    YesNo

    Are you available for part-time work? :
    YesNo

    Will you relocate? :
    YesNo

    Are you willing to travel? :
    YesNo

    If yes, what percent?* :

    Date you can start* :

    Desired position* :

    Desired starting salary* :

    Please list applicable skills:

    Education

    School Name and Location Year Major/Degree

    High School : Name*

    Location* :

    Year* :

    College Name* :

    Location* :

    Year* :

    Post-College Name* :

    Location* :

    Year* :

    Other Training Name* :

    Location* :

    Year* :

    In addition to your work history, are there are other skills, qualifications, or experience that we should consider?

    Please list any scholastic honors received and offices held in school.

    Are you planning to continue your studies? :
    YesNo

    If yes, where and what courses of study?

    Employment History (Start with the most recent employer)

    Company Name* :

    Address* :

    Telephone* :

    Starting Position* :

    Date Started* :

    Starting Wage* :

    Telephone* :

    Date Ended* :

    Ending Wage* :

    Ending Position* :

    Name of Supervisor:

    May we contact? :
    YesNo

    Responsibilities:

    Reason for leaving:

    Emergency Contact

    In case of emergency, please notify:

    Name* :

    Phone* :

    Address* :

    Please Read Before Signing:

    I certify that all information provided by me on this application is true and complete to the best of my knowledge and that I have withheld nothing that, if disclosed, would alter the integrity of this application.
    I authorize my previous employers, schools, or persons listed as references to give any information regarding employment or educational record. I agree that this company and my previous employers will not be held liable in any respect if a job offer is not extended, or is withdrawn, or employment is terminated because of false statements, omissions, or answers made by myself on this application. In the event of any employment with this company, I will comply with all rules and regulations as set by the company in any communication distributed to the employees.
    In compliance with the Immigration Reform and Control Act of 1986, I understand that I am required to provide approved documentation to the company that verifies my right to work in the United States on the first day of employment. I have received from the company a list of the approved documents that are required.
    I understand that employment at this company is “at will,” which means that either I or this company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I hereby acknowledge that I have read and understand the above statements.

    Signature* :

    Date* :