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Serving Rutherford & McDowell Counties
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HOSPICE OF RUTHERFORD COUNTY, INC STAFF APPLICATION
Name:
Last
First
Middle
Maiden
Address:
City:
State:
Zip code :

Job(s) for which you are applying (Specific titles)
1)
2)
3)
Please indicate referral source:
If you were referred by the Employment Security Commission (Job Service) please indicate which local office:
Are you qualified to work in the United States? Yes No

References:
1)
2)
3)

Education:
Schools: Name and Location Dates attended (From - To) Type of Degree
High School:
College(s):
Graduate or Professional:
Vocational schools or internships:
Special training programs and seminars attended in the last five years:
If the job applied for requires specific courses, indicate those courses taken and credits received:

Current Professional Status:

List fields of work for which you have been registered:
Registration: State: No:
Membership in professional, honorary, or technical societies (list):
License and certifications (list, give dates and sources of issuance):
CHECK the following SKILL, EXPERIENCE, etc which you have:
Driver’s license: No: State: Sign Language:
Chauffeurs license: No: State: Foreign Language:
Car for use at work:
Adding machine/calculator:
Typing (wpm):
Shorthand/speedwriting (wpm):
Legal/Medical transcription:
Word processing skills:
Braille skills:
Other:
Have you ever been convicted of an offense against the law other than a minor traffic violation? (A conviction does not mean you cannot be hired. The offense and how recently you were convicted will be evaluated in relations to
the job for which you are applying)
Yes No
(if yes)

WORK HISTORY:

(include volunteer experience)
Current or last employer:
Address:
Job title:
Supervisor’s name:
Phone No:
No. supervised by you:
Date employed:
Date separated:
Starting salary: $ per
Ending or current salary: $ per
Reason for leaving:
May we contact employer? Yes No
Full time: Years: Months:
Part-time: Years: Months: Hours worked per week:
Employer:
Address:
Job title:
Supervisor’s name:
Phone No:
No. supervised by you:
Date employed:
Date separated:
Starting salary: $ per
Ending or current salary: $ per
Reason for leaving:
May we contact employer? Yes No
Full time: Years: Months:
Part-time: Years: Months: Hours worked per week:
Employer:
Address:
Job title:
Supervisor’s name:
Phone No:
No. supervised by you:
Date employed:
Date separated:
Starting salary: $ per
Ending or current salary: $ per
Reason for leaving:
May we contact employer? Yes No
Full time: Years: Months:
Part-time: Years: Months: Hours worked per week:
Employer:
Address:
Job title:
Supervisor’s name:
Phone No:
No. supervised by you:
Date employed:
Date separated:
Starting salary: $ per
Ending or current salary: $ per
Reason for leaving:
May we contact employer? Yes No
Full time: Years: Months:
Part-time: Years: Months: Hours worked per week:

*WE ARE AN AT-WILL, EQUAL OPPORTUNITY EMPLOYER*
I certify that the answers given in this application are true and complete to the best of my knowledge. I authorize investigation into all statements I nave made on this application as may be necessary for reaching an employment decision. In the event in employed, I understand that any false or misleading information I knowingly provide in my application or interview(s) may result in discharge and/or legal action. I understand also that if employed, I am required to abide by all rules and regulations of the employer and any special agreements reached between the employer and me.
Yes No
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Hospice of Rutherford offers hospice care, palliative care,
and grief counseling services for those in Rutherford and McDowell Counties.

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