Application

Applicants are considered for all positions without regard to race, color, religion, gender national origin, age, genetic information or any other status protected by law or regulations. It is our intention that all qualified applicants be given equal opportunity and that selection decisions are based on job-related factors.

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Applicant Name

Education

High School or GED College or University College or University Trade or Other Prof. School

Availability

Are you available to work? (Please select all that apply.)

If hired, you will be required to furnish proof of your eligibility to work in the United States. (Proof of citizenship or immigration status is required as a condition of employment.) Completion of a formal background check will be required as a condition of employment.

Work History

List names of employers in consecutive order with present listed first. Account for the last 7 years, including military service and any periods of unemployment. If self-employed, give firm name and supply business references.

Note: A job offer will be contingent upon acceptable references from current and former employers.

Employed Pay
Employed Pay
Employed Pay
Employed Pay
Have you worked or attended school under any other names?
Are you presently employed? If yes, may we contact?
Have you ever been terminated from a job or asked to resign?
Have you been convicted of a criminal offense within the last 7 years?

References

Please provide three professional references (manager, supervisor, or co-worker).

AFFIDAVIT, CONSENT AND RELEASE

Please read each statement carefully before signing

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.

I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand I will be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment.

I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.

I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMIANTED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.

I have read, understand, and by my signature consent to these statements.

   


FAIR CREDIT REPORTING ACT DISCLOSURE & AUTHORIZATION

DISCLOSURE

Pikes Peak Hospice & Palliative Care (PPHPC), when considering your application for employment, when making a decision whether to offer you employment, when deciding whether to continue your employment (if you are hired), and when making other employment-related decisions directly affecting you, may wish to obtain and use a “consumer report” from a “consumer reporting agency” about you. These terms are defined in the Fair Credit Reporting Act, which applies to you. As an applicant for employment or employee of PPHPC, you are a “consumer” with rights under the FCRA.

A “consumer reporting agency” is a person or business which, for monetary fees, dues, or on a cooperative nonprofit basis, regularly assembles or evaluates consumer credit information or other information on consumers for the purpose of furnishing “consumer reports” to others, such as PPHPC.

A “consumer report” is any written, oral or other communication of any information by a “consumer reporting agency” bearing on a consumer’s credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or collected for the purpose of serving as a factor in establishing the consumer’s eligibility for employment purposes. (A formal background check is a requirement for hire. A motor vehicle record check is a requirement for hire for those positions utilizing a vehicle as part of their daily or almost daily work activities.)

If PPHPC obtains a “consumer report” about you, and if PPHPC considers any information in the “consumer report” when making an employment-related decision that directly and adversely affects you, you will be provided with a copy of the “consumer report” before the decision is made final by PPHPC. You are also free to contact the Federal Trade Commission about your rights under the FCRA, as a “consumer,” with regard to “consumer reports” and “consumer reporting agencies.”

AUTHORIZATION

By signing below, I, , hereby voluntarily authorize PPHPC to obtain “consumer reports” about me from a “consumer reporting agency” and to consider the “consumer reports” when making decisions regarding my employment at PPHPC. I understand that I have rights under the Fair Credit Reporting Act, including the rights discussed above.

   

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