Employment

Step 1

Personal Information

indicates a required field

First Name

Middle Name

Last Name

Address

Address 2

City

State

Zip

Home Phone

Cell Phone

Business Phone

Desired Contact Method

Home

Business

Cell

Are you over 18?

Yes

If no, can you provide required proof of your eligibility to work?

Yes

After employment, can you submit proof of your U. S. citizenship or immigration status?

Yes

Have you ever been convicted of any crime?

Yes

If Yes, please explain.

Conviction will not necessarily disqualify an applicant from employment.

Are you willing to submit to drug testing at the direction of Hospice & Palliative Care of Iredell County?

Yes

Step 2

Employment Desired

indicates a required field

Position(s) applying for

How did you learn about Hospice & Palliative Care of Iredell County?

Employment Agency

Friend

Relative

Walk-in

Other

Type of Preferred Status

Full Time

Part Time Agency

Temporary

Any

Salary Expectations

Per Hour

Per Year

Date Available for Employment

Hours Preferred

Have you ever applied for employment with us?

Yes

If yes, give date

Type of Availability

Saturdays

Sundays

Holidays

Overtime

Other

Hospice & Palliative Care of Iredell County, 2347 Simonton Road, Statesville, NC 28625 is an equal opportunity employer and does not discriminate in its employment practices on the basis of race, color, veteran status, gender, age, creed, religion, disability, or national origin.

This application will be given every consideration; its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all questions have been answered.

Step 3

Education & Training

indicates a required field

High School

Name and Location of School

Course of Study

Years Completed

Diploma/Degree

Did you graduate?

Yes

Business/Trade/Tech School

Name and Location of School

Course of Study

Years Completed

Diploma/Degree

Did you graduate?

Yes

College

Name and Location of School

Course of Study

Years Completed

Diploma/Degree

Did you graduate?

Yes

Graduate School

Name and Location of School

Course of Study

Years Completed

Diploma/Degree

Did you graduate?

Yes

Describe any specialized training, skills, apprenticeships and extracurricular activities. Also indicate any foreign language(s) you can speak, read and/or write:

List membership in professional, trade, business or civic organizations and offices held (exclude those which may reveal your gender, race, religion, national origin, age, disability or other protected status):

Did you serve in the U. S. Armed Forces?

Yes

If Yes, describe any training received relevant to the position to which you are applying:

Step 4

Employment History

indicates a required field

Start with your present or most recent employer. Give accurate, complete information accounting for all periods of time including military service and any periods of unemployment. Please give month and year.

Company

Name

Phone

Address

Job Title

Employed From

Month

Year

Month

Year

Immediate Supervisor

Supervisor Title

Pay Rate

Start

Per

Final

Per

Reason for Leaving

Duties Performed

Company

Name

Phone

Address

Job Title

Employed From

Month

Year

Month

Year

Immediate Supervisor

Supervisor Title

Pay Rate

Start

Per

Final

Per

Reason for Leaving

Duties Performed

Company

Name

Phone

Address

Job Title

Employed From

Month

Year

Month

Year

Immediate Supervisor

Supervisor Title

Pay Rate

Start

Per

Final

Per

Reason for Leaving

Duties Performed

Step 5

Supplemental Employment Information

indicates a required field

If you ever worked in any of your previous positions under another name, please give that name(s)

Are you presently employed?

Yes

If Yes, may we contact your present employer?

Yes

Have you ever been fired, or asked to resign, from a job?

Yes

If Yes, please explain:

Are you related to any current employee, volunteer, or board member at Hospice & Palliative Care of Iredell County?

Yes

Step 6

References

Give three references listing name, address, phone number, and occupation. Do not list relatives or former employers.

Reference 1

Name

Phone

Address

Occupation

Email Address

Reference 2

Name

Phone

Address

Occupation

Email Address

Reference 3

Name

Phone

Address

Occupation

Email Address

Step 7

Affidavit & Release Authorization

Affidavit

I certify that my answers to the foregoing questions are true and correct without and consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading or otherwise incorrect statements made on this application form, any inserts/attachments or during any interviews may be grounds for immediate dismissal.
I hereby authorize Hospice & Palliative Care of Iredell County to contact any company or individual it deems appropriate to investigate my employment history, character, and qualifications. I give my full and complete consent to their revealing any and all information they wish as a result of this investigation. In addition, I hereby waive my right to bring any cause of action against these individuals for defamation, invasion of privacy, or any other reason because of their statements.
I agree that, if I am employed, I will abide by all the rules and regulations of Hospice & Palliative Care of Iredell County. I will also adhere to the CORE VALUES of Hospice & Palliative Care of Iredell County.
I understand this application shall be considered active for a period of time not to exceed ninety (90) days. If I wish to be considered for employment beyond this time period, I should inquire whether aplications are being accepted at that time.
HPCIC has/will soon mandate COVID vaccinations as a condition of employment. Exemptions are allowed for medical or religious reasons but must be documented and approved prior to employment.

By checking this box, I certify that I agree to the above statements.

Release Authorization

Full Name

Maiden Name or Other Name Used

Driver's License Number

State Issued

Date of Birth

Race

Sex

Male

Female

List States and Counties of residence other than that above, for the past seven years.

State

County

State

County

State

County

State

County

In consideration of my application, I authorize Hospice & Palliative Care of Iredell County, Inc, by and through QPI to verify all data given by me on application, related papers or oral interviews. I understand a thorough investigation may be conducted which may include but not be limited to criminal history, motor vehicle driving record, education verification, employment history, credit report and personal history. I hereby authorize employers, agencies, personal references and other persons with whom I am acquainted to answer all questions and release all information concerning my employment record, character, reputation, ability, education, military service, credit history and other applicable reports. Furthermore, I release all agencies, bureaus, employers, information service organizations, and individuals or companies named above from all liabilities of damages that might result from information provided in good faith. I state that the information provided by me on my application is accurate and I agree that if any information therein is found to be false at any time, my application may be discarded or my employment terminated. I understand that the information requested below regarding sex, race and date-of-birth are for the sole purpose of gathering the above information accurately and will not be used to discriminate against me in violation of the law.

I certify that all the information contained in my employment application is true to the best of my knowledge. I further understand that if I am given the opportunity to begin employment with Hospice & Palliative Care of Iredell County, prior to completion of my background investigation and it is determined that I gave false statements, or any omission of a material fact, I may be subject to immediate discharge.

By checking this box, I certify that have read and agree to the above authorization.

Careers

Employment Application

Step 1

Personal Information

Step 2

Employment Desired

Step 3

Education & Training

Step 4

Employment History

Step 5

Supplemental Employment Information

Step 6

References

Step 7

Affidavit & Release Authorization

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