Employment Application

Home
What is Hospice?
Hospice Stories
Grief Support
- Patient and Family Grief Support
- Community Bereavement Services
  - 15th Annual Camp Bridges - May 2010
Get Involved
Hospice Careers
Giving
Contact Us
- Directions

Welcome to our Employee Application. You may choose one of two methods to complete the application.

First, you may fill out the form below online and submit. If you are invited for an interview, we will ask you for authorization to complete a criminal background check which may include fingerprints and employment verification at that time.

Or, secondly, you may click here to print the application, complete and return either by scan / email to:

recruiter@cornerstonehospice.org; fax to 352-343-0324; hand deliver to any of our locations; or, mail to:

Gail Kennedy, Recruitment Specialist
2445 Lane Park Road
Tavares, FL 32778

Thank you for your interest.

Personal Info

Position Applied for:
Name:
Address:
Mailing Address:
Telephone:
Cell:
Other Phone:
Email:
Are you at least 18 years old?:
Y N
If under 18 years of age, please state your age for Child Labor Law purpose only:
Can you, within three days of employment, submit documentation verifying that you are legally eligible to work in the United States?:
Y N
Have you ever been employed by Cornerstone Hospice?:
Y N
If yes, position:
Dates of Employment:
Are you interested in:
FT PT PRN (as needed)
Have you ever applied at Cornerstone Hospice?:
Y N
If yes, position:
How were you informed of this opening?: Current Employee:
Y N
If yes, name of employee: Friend Relative Website Other Job Fair Newspaper Walk-In
Name of Website, newspaper, other:

Licensure

Professional Licensure:
License:
Profession in which you are licensed, registered or certified:
Are you a FL Certified Nurse's Aide?:
Y N
If yes, License #:
Do you have your Home Health Aide Certification?:
Y N

Education

High School Name/Address:
Years Completed:
Name of Course/Study:
Degree/Diploma:
Y N
College Name/Address:
Years Completed:
Name of Course/Study:
Degree/Diploma:
Y N
College Name/Address:
Years Completed:
Name of Course/Study:
Degree/Diploma:
Y N
College Name/Address:
Years Completed:
Name of Course/Study:
Degree/Diploma:
Y N

Driving

Do you have a valid Florida Driver's License?:
Y N
Have you ever had any traffic citations?:
Y N
If yes, explain:
Has your driver's license ever been suspended or revoked?:
Y N
If yes, explain:
Do you have any DUI or DWI convictions?:
Y N
If yes, explain:

General

Have you ever been discharged or forced to resign from employment?:
Y N
If yes, explain:
Have you ever been convicted of a felony?:
Y N
If yes, please list dates and circumstances:
I understand that field and direct care positions may be scheduled anywhere in the area covered by Cornerstone Hospice, should the need occur.:
Agree
I understand that field and direct care positions may require work any day of the week, including Saturday and Sunday.:
Agree
I understand that field and direct care positions may require work aduring varied shifts, including days, eveninge, and night-time hours.:
Agree
Have you been unemployed at any time since leaving school?:
Y N
If yes, please give dates and reasons:
Are you currently employed?:
Y N
If applicable, may we contact your present employer?:
Y N

References

List three professional references of persons not related to you whom you have known at least one year. Name:
Telephone#:
Company:
Years Acquainted:
Address:
Name:
Telephone#:
Company:
Years Acquainted:
Address:
Name:
Telephone#:
Company:
Years Acquainted:
Address:

Skills

Skills Inventory:
Computer/PC Postage Meter Microsoft Excel Desktop Publishing Microsoft Outlook Microsoft Word Microsoft Powerpoint Microsoft Access Second Language Venipuncture Pumps IV Access (ports) Catherization Tubes (feeding, GI, NG)
List any machines, software or equipment you can demonstrate competency in not mentioned above:

Employment

Company:
Telephone#:
Address:
Job Title:
Salary:
Duties:
Supervisor Name:
Title:
Employed from (mm/yy):
to (mm/yy):
Reason for Leaving:
Company:
Telephone#:
Address:
Job Title:
Salary:
Duties:
Supervisor Name:
Title:
Employed from (mm/yy):
to (mm/yy):
Reason for Leaving:
Company:
Telephone#:
Address:
Job Title:
Salary:
Duties:
Supervisor Name:
Title:
Employed from (mm/yy):
to (mm/yy):
Reason for Leaving:
Company:
Telephone#:
Address:
Job Title:
Salary:
Duties:
Supervisor Name:
Title:
Employed from (mm/yy):
to (mm/yy):
Reason for Leaving:
Company:
Telephone#:
Address:
Job Title:
Salary:
Duties:
Supervisor Name:
Title:
Employed from (mm/yy):
to (mm/yy):
Reason for Leaving:
Company:
Telephone#:
Address:
Job Title:
Salary:
Duties:
Supervisor Name:
Title:
Employed from (mm/yy):
to (mm/yy):
Reason for Leaving: