Sally Weber Human Resources Coordinator

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1 Dear Applicant: Thank you for your interest in Niagara Hospice. Our agency is committed to excellence in serving those facing end of life challenges. We strive to maintain the highest level of dignity, integrity, quality and respect for the patients and families we serve. Niagara Hospice employees are an integral part of this mission. In order to be considered for an interview with Niagara Hospice you must complete all of the requirements listed below. New Applicant Requirements: A. Completed Application and Resume with cover letter B. Letter of Intent Provide a letter detailing why you think you are the best candidate for the position, why you want to work for Niagara Hospice and what special qualities make you the best choice. C. References Two employment references and one personal reference are required. The forms are included in this packet or you can submit three written letters of reference. D. Consent form for Criminal Background Check Also included in the packet is consent for a criminal background check and a driver s license check. E. A copy of your Professional License or Certificate if applicable Once our interview team reviews all of the above information, you will be contacted. If you have any questions, please feel free to contact me at (716) Sincerely, Sally Weber Human Resources Coordinator

2 Niagara Hospice APPLICATION FOR EMPLOYMENT PERSONAL INFORMATION DATE: Name Last First Middle SS# Present Address Street City State Zip Permanent Address Street City State Zip Phone No. Are you 18 years or older Yes No Address: Are you either a U.S. Citizen or an alien authorized to work in the United States? Yes No Have you ever been convicted of a crime? If so explain: EMPLOYMENT DESIRED DATE YOU SALARY POSITION CAN START DESIRED IF SO MAY WE INQUIRE ARE YOU EMPLOYED NOW? OF YOUR PRESENT EMPLOYER? EVER APPLIED TO THIS COMPANY BEFORE? WHERE? WHEN? REFERRED BY EDUCATION NAME & LOCATION OF SCHOOL # OF YEARS ATTENDED GRAMMAR SCHOOL HIGH SCHOOL COLLEGE TRADE, BUSINESS OR CORRESPONDENCE SCHOOL DID YOU GRADUATE? SUBJECTS STUDIED GENERAL SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK SPECIAL SKILLS: ACTIVITIES: (CIVIC, ATHLETIC, ETC) EXCLUDE ORGANIZATIONS, THE NAME OF WHICH INDICATES THE RACE, CREED, SEX, AGE, MARITAL STATUS, COLOR OR NATION OR ORIGIN OF ITS MEMBERS U.S. MILITARY PRESENT MEMBERSHIP IN NAVAL SERVICE RANK NATIONAL GUARD OR RESERVE The Age Discrimination in Employment Act of 1987 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age. (CONTINUED)

3 EMPLOYMENT HISTORY: LIST EMPLOYERS FROM MOST RECENT TO PAST EMPLOYER ADDRESS/PHONE NUMBER DATES TO/FROM SALARY DUTIES/JOB TITLE REASON FOR LEAVING: EMPLOYER ADDRESS/PHONE NUMBER DATES TO/FROM SALARY DUTIES/JOB TITLE REASON FOR LEAVING: EMPLOYER ADDRESS/PHONE NUMBER DATES TO/FROM SALARY DUTIES/JOB TITLE REASON FOR LEAVING: EMPLOYER ADDRESS/PHONE NUMBER DATES TO/FROM SALARY DUTIES/JOB TITLE REASON FOR LEAVING: REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR. NAME ADDRESS BUSINESS YEARS ACQUAINTED IN CASE OF EMERGENCY NOTIFY: NAME ADDRESS PHONE NO. 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 LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU. I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE AND WITHOUT CAUSE. DATE SIGNATURE The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the gender, race/national origin of the individual applicants on the basis of visual observation or surname. Gender: Male Female Ethnicity: Hispanic or Latino Not Hispanic or Latino Race: (Mark one or more) White Black of African American American Indian/Alaskan native Asian Native Hawaiian or Other Pacific Islander

4 THE HOSPICE AND PALLIATIVE CARE GROUP, INC. NIAGARA HOSPICE, INC. PALLIATIVE HOME CARE OF NIAGARA, INC. NIAGARA HOSPICE ALLIANCE, INC. HR 5.0c EMPLOYMENT REFERENCE REQUEST To: (Print Name and Address of Former Employer below) Phone # I have applied for employment with Niagara Hospice and hereby authorize you to furnish the information requested below concerning my prior employment with your organization. In signing this authorization, I release your organization, its employees and/or its agents from any liability that may result now or later because of complying with this request. Employee s Signature: Date: TO BE COMPLETED BY EMPLOYEE: (Name: Last, First, Middle Initial) (Social Security Number) Employment Dates: From: to: Last Position Reason for leaving TO BE COMPLETED BY EMPLOYER: Are employment dates correct? Yes No If no, what are correct dates? From to: Is the position title correct? Yes No If no, what is the correct title? Is reason for leaving correct? Yes No If no, what is correct reason? Is applicant eligible for rehire? Yes No If no, why? OVERALL ASSESSMENT: Attendance Good Satisfactory Poor Punctuality Good Satisfactory Poor Performance Good Satisfactory Poor Completed by: Title: Date: Please return Employee Reference form in envelope provided.

5 THE HOSPICE AND PALLIATIVE CARE GROUP, INC. NIAGARA HOSPICE, INC. PALLIATIVE HOME CARE OF NIAGARA, INC. NIAGARA HOSPICE ALLIANCE, INC. HR 5.0c EMPLOYMENT REFERENCE REQUEST To: (Print Name and Address of Former Employer below) Phone # I have applied for employment with Niagara Hospice and hereby authorize you to furnish the information requested below concerning my prior employment with your organization. In signing this authorization, I release your organization, its employees and/or its agents from any liability that may result now or later because of complying with this request. Employee s Signature: Date: TO BE COMPLETED BY EMPLOYEE: (Name: Last, First, Middle Initial) (Social Security Number) Employment Dates: From: to: Last Position Reason for leaving TO BE COMPLETED BY EMPLOYER: Are employment dates correct? Yes No If no, what are correct dates? From to: Is the position title correct? Yes No If no, what is the correct title? Is reason for leaving correct? Yes No If no, what is correct reason? Is applicant eligible for rehire? Yes No If no, why? OVERALL ASSESSMENT: Attendance Good Satisfactory Poor Punctuality Good Satisfactory Poor Performance Good Satisfactory Poor Completed by: Title: Date: Please return Employee Reference form in envelope provided.

6 THE HOSPICE AND PALLIATIVE CARE GROUP, INC. NIAGARA HOSPICE, INC. PALLIATIVE HOME CARE OF NIAGARA, INC. NIAGARA HOSPICE ALLIANCE, INC. HR 5.0c PERSONAL REFERENCE REQUEST To: (Print Name and Address of Reference below) Phone # I have applied for employment with Niagara Hospice and hereby authorize you to furnish the information requested below. I would be most grateful if you could assist us by completing this form and returning it to me in the envelope provided. TO BE COMPLETED BY EMPLOYEE: Employee s Signature: Date: (Print Name) TO BE COMPLETED BY PERSONAL REFERENCE: How long and in what capacity have you known this candidate? Would you feel comfortable with this person taking care of a family member? OVERALL ASSESSMENT: Reliability Good Satisfactory Poor Honesty Good Satisfactory Poor Trustworthy Good Satisfactory Poor Completed by: Date: Please return in the envelope provided.

7 If you do not have a resume please fill out this form. If you need more room please attach a separate sheet of paper. RESUME NAME: ADDRESS: CITY: STATE: ZIP: PHONE: ADDRESS: PLEASE COMPLETE IN FULL THE INFORMATION BELOW. (If you require more space for the information requested below please complete on the back of this form.) EDUCATION: WORK EXPERIENCE: SPECIAL SKILLS

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