APPLICATION FOR EMPLOYMENT - Visiting Nurse & Hospice Care

Employer Dates Employed Worked PerformedFromToAddressTelephone Number(s)Hourly Rate/SalaryStarting FinalPosition/Job TitleSupervisorReason for LeavingIf you need additional space, please continue on a separate sheet of paper.Special Skills and QualificationsSummarize special skills and qualifications acquired from employment or other experience. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________*PLEASE READ, INITIAL ON THE LINE AT THE END OF EACH PARAGRAPH, AND SIGN BELOW*I certify that the information provided in this application is true and complete to the best of my knowledge. I furthercertify that I, the undersigned applicant, have personally completed this application. I understand that anyfalsification, omission, misrepresentation or concealment of information on this application, during interviews, or atany other time during the hiring process may result in rejection of this application or, if hired, may result in disciplineup to and including dismissal, regardless of the time elapsed before discovery. ______I hereby authorize Visiting Nurse & Hospice Care of Santa Barbara to thoroughly investigate my references, workrecords, and other matters related to my suitability for employment and, further, authorize my former and currentemployers to disclose to the company any and all letters, reports and other information related to my work history. Inaddition, I hereby release the company, my former employers and all other persons, corporations, partnerships andassociations from any and all claims, demands or liabilities arising out of or in any way related to such investigation ordisclosure. ______I understand that nothing contained in the application or conveyed during any interview which may be granted isintended to create an employment contract between me and Visiting Nurse & Hospice Care. I also understand that alloffers of employment are conditional upon satisfactory reference checks, completion of Visiting Nurse & HospiceCare’s standard confidentiality agreement and production of documents necessary for Visiting Nurse & Hospice Careto verify identity and work authorization in accordance with the USCIS form I-9. I also understand that a company paiddrug test and/or physical examination and background and/or credit check may be required and if performed,employment would be contingent upon satisfactory results. I also authorize Visiting Nurse & Hospice Care to conductany of the foregoing. ______I understand and agree that my employment is at-will and I may terminate my employment at any time without causeor notice; similarly, my employment may be terminated or my status changed (for example, my position may bechanged, I may be demoted, or my benefits may be changed) by the Company at any time without cause or notice. Ialso understand that this at-will agreement will remain in effect throughout the duration of my employment and mayonly be changed by a written agreement signed by the President/CEO of Visiting Nurse & Hospice Care. ______Applicant’s Signature: ____________________________________________Date: _____________________Print Name: ____________________________________________________ rev 6/105