Career Opportunities at United Hospice of Rockland
Employment Application
 
Position Applying For: 
Name:
Address:
Home Telephone: Business Telephone:
Applying for: Full Time   Part Time    Per Diem  
Available Start Date:
Are you available to work overtime as necessary?       Yes    No
Have you been convicted of a crime?   Yes    No
If yes, state nature of offense, when, where and disposition:
Have you ever been excluded from participation in the federal health care program?        Yes    No
Educational History
Name/Address of High School:
Name/Address of College:
 		Number of years completed? 
Degree Received?   
Name/Address of College:
 		Number of years completed? 
Degree Received?   
Graduate School:
 		Number of years completed? 
Degree Received?   
Course of Study:
Other Schools:

Course of Study:  		Number of years completed? 
Degree Received?   
Licenses/Certificates held, Field(s) of Practice, Dates Obtained:

Special Skills/Talents:
Are you a veteran?      Yes    No   If so, are you a combat veteran?  Yes    No

What war?

Please read the provided job description for the position you are applying for.  Check one of the statements:

I have reviewed the job description for the position for which I have applied.  I am capable and qualified to perform all job functions.

The following accommodations would be necessary for me to perform all job functions:
Work Experience (List in order with last or current employer)
Date From/To:             Position Held: 
Reason for Leaving:
Did you work:  Full Time   Part Time    Per Diem  
Name/Address/Telephone Number of Employer:  
Salary: Supervisor's Name/Title:
Comments:
 
Date From/To:             Position Held: 
Reason for Leaving:
Did you work:  Full Time   Part Time    Per Diem
Name/Address/Telephone Number of Employer:  
Salary: Supervisor's Name/Title:
Comments:
 
Date From/To:             Position Held: 
Reason for Leaving:
Did you work:  Full Time   Part Time    Per Diem  
Name/Address/Telephone Number of Employer:  
Salary: Supervisor's Name/Title:
Comments:
 
May we contact ALL of the employers listed for references? Yes    No
(Specify if necessary)
Personal References (excluding relatives)

Name/Address/Telephone Number:  

Name/Address/Telephone Number:  
After submitting form, please submit resume to: ogilman@hospiceofrockland.org

Please note, your file name cannot have spaces.   resume.doc is acceptable.  Preferably firstnamelastname.doc - ex: johndoeresume.doc
 

UNITED HOSPICE OF ROCKLAND, INC.
 United Hospice of Rockland, Inc. (UHR) is an equal opportunity employer and subscribes to Federal and New York State laws prohibiting discrimination in employment because of race, color, religion, sex, national origin, age, marital status, or disability.

PRE-EMPLOYMENT STATEMENT

1.  I certify that the information that I have provided on this application is true and complete to the best of my knowledge.  Any misrepresentation or omission of any fact in my application, resume or any other materials, or during interviews, can be justification for refusal of employment, or, if employed, termination from UHR's employment.

2.  Any offer of employment from UHR I may receive is contingent upon my successful completion of UHR's pre-employment screening process, including receipt of references that it considers satisfactory, and my satisfaction of all postoffer health related requirements.  As part of its screening process, UHR will be conducting the following background checks in accordance with agency policy and consistent with the position I shall hold: criminal background, driving record verification, Excluded Parties Listings / Fraud Alert for Medicaid, Medicare and the Office of the Inspector General.

3.  Upon employment, I will receive a copy of UHR's personnel policies.  I understand that these policies are intended as guidelines only.  The policies may be amended at any time, and depending upon the particular circumstances of a particular situation, management actions may vary from written policy.  The contents of UHR policies do not constitute a guarantee of continued employment.  Rather, employment with UHR is on an “at-will” basis.  This means that the employment relationship may be terminated at any time by either employee or management for any reason not expressly prohibited by law.


 
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