ࡱ> GIFM bjbj== WWyl  8T 1.ee"%%%"1$1$1$1$1$1$1$2  5H1 %".%%%H1& ]1&&&&%(( "1&%"1&&F)  ~Xz{X@ F)Y 3P1 &LF)@F)1<1F)5P&L5F)& PORTSBRIDGE HOSPICE APPLICATION FOR EMPLOYMENT PRE-EMPLOYMENT QUESTIONNAIRE AN EQUAL OPPORTUNITY EMPLOYER PERSONAL INFORMATION LAST NAME FIRST NAME Middle Name SOCIAL SECURITY NO.PRESENT ADDRESS APT. NO.CITYSTATEZIPPERMANENT ADDRESS APT. NO.CITYSTATEZIPARE YOU 18 YEARS OR OLDER? YES NO Yes NoPHONE Day - Even. - DESIRED EMPLOYMENT POSITION DATE YOU CAN STARTSALARY DESIREDARE YOU EMPLOYED NOW? YES NO IF SO, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER? YES NOAPPLIED TO THIS COMPANY BEFORE? YES NO WHERE?WHEN? WORKED FOR THIS COMPANY BEFORE? YES NO WHERE?WHEN?REASON FOR LEAVING  NAME OF LAST SUPERVISOR AT HIS COMPANY WHO REFERRED YOU TO THIS COMPANY? EMPLOYMENT AGENCY NEWSPAPER ADVERTISING FRIEND STATE EMPLOYMENT OFFICE COLLEGE PLACEMENT SERVICE WALK IN OTHER EDUCATION SCHOOL LEVELNAME AND LOCATION OF SCHOOLNO. OF YEARS ATTENDEDDID YOU GRADUATE?SUBJECT STUDIED GRAMMAR SCHOOL  HIGH SCHOOL  COLLEGE  TRADE, BUSINESS OR ORRESPONDENCE SCHOOL  GENERAL SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK SPECIAL TRAINING SPECIAL SKILLS FORMER EMPLOYERS LIST BELOW LAST THREE EMPLOYERS, STARTING WITH THE MOST RECENT ONE FIRST NAME OF PRESENT OR LAST EMPLOYER ADDRESS CITYSTATEZIP STARTING DATELEAVING DATEJOB TITLE WEEKLY STARTING SALARYWEEKLY FINAL SALARY MAY WE CONTACT YOUR SUPERVISOR? YES NONAME OF SUPERVISOR TITLEPHONE DESCRIPTION OF WORK  REASON FOR LEAVING  NAME OF PREVIOUS EMPLOYER ADDRESSCITYSTATEZIP STARTING DATELEAVING DATEJOB TITLE WEEKLY STARTING SALARYWEEKLY FINAL SALARYMAY WE CONTACT YOUR SUPERVISOR? YES NO NAME OF SUPERVISORTITLE PHONE DESCRIPTION OF WORK REASON FOR LEAVING  NAME OF PREVIOUS EMPLOYER ADDRESSCITYSTATEZIP STARTING DATELEAVING DATEJOB TITLE WEEKLY STARTING SALARY WEEKLY FINAL SALARYMAY WE CONTACT YOUR SUPERVISOR? YES NO NAME OF SUPERVISORTITLE PHONE DESCRIPTION OF WORK REASON FOR LEAVING  REFERENCES BELOW, GIVE THE NAMES OF THREE PERSONS YOU ARE NOT RELATED TO, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR. NAMEADDRESSBUSINESSYEARS ACQUAINTED 1  2  3  SERVICE RECORD BRANCH OF SERVICE DISCHARGE DATE RANK      HAVE YOU BEEN ARRESTED AND/OR CONVICTED OF A FELONY? YES NOIF YES, EXPLAIN. (WILL NOT NECESSARILY EXCLUDE YOU FROM CONSIDERATION)     AUTHORIZATION " I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES AND EMPLOYERS LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE AND RELEASE THE COMPANY FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION. I ALSO UNDERSTAND AND AGREE THAT NO REPRESENTATIVE OF THE COMPANY HAS ANY AUTHORITY TO ENTER INTO ANYAGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING, UNLESS IT IS IN WRITING AND SIGNED BY AN AUTHORIZED COMPANY REPRESENTATIVE" ___________________________________________________________________________________________________________________ DATE SIGNATURE  PORTSBRIDGE HOSPICE PAGE  PAGE 3  EMBED MS_ClipArt_Gallery       EMBED MS_ClipArt_Gallery   0C9:deuwy{WXmq< = ? @ + , > C R W a f I j l k ǻ5CJOJQJ5CJOJQJ5B*CJphj5UmHnHuj5CJUmHnHuj5CJUmHnHu5CJ55CJ(5CJ5CJjUmHnHu@ R#$%9 0$If]0 0]0^ 0]0^ 0P]0^P`0]0$0]0a$ 9:JKLUZ`d 0$If]0l$$Ifl0D%rH04 ladewxy[QQQQQQQ[ 0$If]0$$Ifl4r. 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