DATE
EOC
POSITION APPLIED FOR
Last Name
First Name
Telephone Number
M.I.
_____ FACILITY
Cell Phone /Other Contact #
_____ HOME CARE
SALARY DESIRED
Number Of Years At Current Address
Current Address:
Social Security Number
Street
Apt #
City
Are You Authorized To Work In US? ____YES ____ NO
If No, Please Explain:
State
Zip
Are You At Least 18 Years Of Age? _____ Yes
_____ No
If No, Please Indicate Age: ___________________________________
(If You Are Under 18 We May Require Proof Of Age & Work Permit.)
Shift Preference:
_____ Days
_____ Nights
_____ Evenings
_____ Weekends Only
_____ Any
Days/Hours Not Available To Work: _____________________________________________________________________________
What Date Will You Be Available To Start Work? _____/ _____/ _____ Can You Travel If The Job Requires It? ________________
Type Of Employment Desired:
_____ Full Time
_____ Part Time
List Any Relatives Employed With Our Company:
_____ PRN/Casual
_____ Temporary
_____ Weekends Only
___________________________________________________________________
Relationship: _____________________________________________________________________________________________________
Have You Ever Completed An Application With Us Before? _____
Have You Been Employed With Our Company Before?
_____
Yes
Yes
_____ No
Date Of Application: _________________
_____ No
Employment Dates: __________________
How Did You Hear/Learn About Our Company?
_____ Advertisement
_____ Walk In
_____
_____ Other, Please Specify: ___________________________________________________________
Employment Agency
_____ Referral By Current Employee: _________________________________
 Have you ever been convicted or pled nolo contender of a MISDEMEANOR or FELONY, other than minor traffic
violations and/or placed on probation, fined or given a suspended sentence in court? _____ YES * _____ NO
*Explain below: ( Include any convictions by military trial and any criminal charges for which you are awaiting trial. List all cases other
than minor traffic violations. (Driving under the influence, reckless or hit and run driving are not minor traffic violations). Please note: A
full disclosure by you is to your advantage, as your record does not constitute an automatic bar to employment. HOWEVER, FAILURE
TO ADMIT CONVICTIONS WILL RESULT IN DISQUALIFICATION.) ____________________________________________________
______________________________________________________________________________________________
EMPLOYMENT HISTORY
In the spaces below, list your employment history beginning with your most recent employer. Please complete even if attaching a resume.
Can we contact your present and previous employers:
________ YES
________ NO
If no, please list the names of the employer(s) you do not want us to contact: ______________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Name and Address of Company
From
Month/Year
To
Month/Year
Position/Title
Name of Supervisor
Name
Street
Description of Duties
City, State, Zip
Reason for Leaving
Telephone Number
Beginning Salary
(
Ending Salary
Days and Hours Worked
)
Name and Address of Company
From
Month/Year
To
Month/Year
Position/Title
Name of Supervisor
Name
Street
Description of Duties
City, State, Zip
Reason for Leaving
Telephone Number
Beginning Salary
(
Ending Salary
Days and Hours Worked
)
Name and Address of Company
From
Month/Year
To
Month/Year
Position/Title
Name
Street
Description of Duties
City, State, Zip
Reason for Leaving
Telephone Number
Beginning Salary
(
)
Ending Salary
Days and Hours Worked
Name of Supervisor
EDUCATION AND TRAINING
School
Name and Location of School
Course of Study
Years
Completed
Did you
Graduate
High School
Yes
No
College
Yes
No
Graduate
School
Yes
No
Other
Studies
Yes
No
Certificate or Degree
Received
PROFESSIONAL CERTIFICATES OR LICENSES
PROFESSION
LICENSE OR
REGISTRATION
STATE ISSUING LICENSE
OR STATE IN WHICH
REGISTERED
LICENSE NUMBER
ADDITIONAL TRAINING
Describe any specialized training and / or apprenticeships
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
SKILLS AND QUALIFICATIONS
Summarize special job related skills and qualifications acquired from employment or other experiences
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
PERSONAL REFERENCES
Give the names of three people (not related to you) whom you have known at least one year.
Name: ________________________________________________
Telephone Number: _________________________
Name: ________________________________________________
Telephone Number: _________________________
Name: ________________________________________________
Telephone Number: _________________________
SIGNATURE AND CERTIFICATION
I hereby affirm that the information provided on this application (and accompanying resume and/or documentation,
if any) is true and complete to the best of my knowledge. I understand that if I am selected for a position, I must be
eligible for employment in the US. I also understand that falsified information or significant omissions may disqualify
me from further consideration for employment, and may be considered justification for dismissal if discovered at a
later date. I further understand that this application becomes property of the Company and will not be returned.
I authorize persons, schools, my current and previous employers and organizations named in this application (and
accompanying documentation), to provide relevant information that may be required to arrive at an employment
decision.
In connection with this application for employment, I understand that a consumer report or investigative consumer
reports which may contain public record information may be requested or made on me including consumer credit,
criminal records, driving record, education, prior employer verification, workers’ compensation claims and others.
These reports will include experience along with reasons for termination of past employment. Further, I understand
that the company will be requesting information from various Federal, State, Local and other agencies which contain
my past activities. I hereby authorize without reservation, any party or agency contacted by this employer to furnish
the above mentioned information. I further authorize ongoing procurement of the above mentioned reports at any
time during my employment.
DRUG TEST CONSENT
(CONSENT FOR PRE-EMPLOYMENT DRUG TEST SCREEN AND RELEASE AGREEMENT)
I hereby CONSENT to allow Tidelands Community Hospice to take a specimen of my hair, urine, or blood and
submit it for a pre-employment, post-accident, or reasonable suspicion drug test screen. I FURTHER CONSENT to
allow the laboratory testing service to make the results of such screen available to the prospective or current
employer, Tidelands Community Hospice.
In consideration for such services being rendered on my behalf, I hereby release the laboratory testing service, its
officers, agents, and employees, from any and all claims which I might otherwise have due to such results being made
so available. I hereby consent not to file any action at law or in equity against Tidelands Community Hospice, the
laboratory testing service, their respective officers, agents or employees in connection with the results of such screen
being made so available, and I hereby agree to indemnify and save harmless Tidelands Community Hospice, the
laboratory testing service, their respective officers, agents, and employees from all damages, expenses, reasonable
attorney's fees, and costs of court which they or any of them may suffer or incur, jointly or severally, due to the
results of such screen being made so available.
I also understand that failure to comply with a drug and/or alcohol testing request or a confirmed positive result for
the illegal use of drugs and/or alcohol will lead to a disqualification of my application or chance of employment with
Tidelands Community Hospice.
IF EMPLOYED, I UNDERSTAND THAT: (1) MY EMPLOYMENT WILL BE “AT-WILL” AND MAY BE TERMINATED BY ME
OR THE COMPANY AT ANY TIME, FOR ANY REASON AND WITHOUT NOTICE; (2) REGARDLESS OF ANY REFERENCES
TO WAGES AS YEARLY, MONTHLY, OR WEEKLY, MY EMPLOYMENT IS NOT FOR A DEFINITE PERIOD OF TIME; (3)
WE MAY REVISE AND MAKE EXCEPTIONS TO THE POLICIES, PRACTICES, HANDBOOKS, MANUALS, RULES, AND
REGULATIONS IN WHOLE OR IN PART, AT ANY TIME; AND (4) UNLESS AGREED TO IN WRITING BY THE OWNERS OF
THE COMPANY NO WRITTEN OR ORAL STATEMENTS I RECEIVE FROM THE COMPANY WILL CHANGE MY STATUS
AS AN “AT WILL” EMPLOYEE.
_____________________________________________
Signature
___________________________________
Date
EQUAL OPPORTUNITY EMPLOYER
WE ARE A DRUG FREE WORKPLACE AND
YOU ARE SUBJECT TO TESTING.
APPLICANT’S AUTHORIZATION FOR RELEASE OF INFORMATION
THIS FORM TO BE COMPLETED AND SIGNED BY JOB APPLICANT
***************************************************************
IN CONNECTION WITH MY APPLICATION FOR EMPLOYMENT (INCLUDING CONTRACT FOR SERVICES), I UNDERSTAND THAT CONSUMER REPORTS OR
INVESTIGATIVE CONSUMER REPORTS WHICH MAY CONTAIN PUBLIC RECORD INFORMATION MAY BE REQUESTED OR MADE ON ME INCLUDING
CONSUMER CREDIT, CRIMINAL RECORDS, DRIVING RECORD, EDUCATION, PRIOR EMPLOYER VERIFICATION, WORKER’S COMPENSATION CLAIMS
AND OTHERS. THESE REPORTS WILL INCLUDE EXPERIENCE ALONG WITH REASONS FOR TERMINATION OF PAST EMPLOYMENT. FURTHER, I
UNDERSTAND THAT YOU WILL BE REQUESTING INFORMATION FROM VARIOUS FEDERAL, STATE, LOCAL AND OTHER AGENCIES WHICH CONTAIN MY
PAST ACTIVITIES.
I HEREBY AUTHORIZE WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THIS EMPLOYER TO FURNISH THE ABOVE MENTIONED
INFORMATION. I HAVE THE RIGHT TO MAKE REQUEST OF THE BACKGROUND CHECK COMPANY, UPON PROPER IDENTIFICATION AND THE PAYMENT
OF ANY AUTHORIZED FEES, FOR THE INFORMATION IN THEIR FILES ON ME AT THE TIME OF MY REQUEST. I FURTHER AUTHORIZE ONGOING
PROCUREMENT OF THE ABOVE MENTIONED REPORTS AT ANY TIME DURING MY EMPLOYMENT (OR CONTRACT).
I UNDERSTAND THAT, PURSUANT TO THE FEDERAL FAIR CREDIT REPORTING ACT, THE EMPLOYER WILL PROVIDE ME WITH A COPY OF ANY SUCH
REPORT IF THE INFORMATION CONTAINED IN SUCH REPORT IS, IN ANY WAY, TO BE USED IN MAKING A DECISION REGARDING MY FITNESS FOR
EMPLOYMENT WITH THE EMPLOYER. I FURTHER UNDERSTAND THAT SUCH REPORT WILL BE MADE AVAILABLE TO ME, ALONG WITH THE NAME
AND ADDRESS OF THE REPORTING AGENCY THAT PRODUCED THE REPORT.
PRINT FULL NAME_____________________________________________________________________
PREVIOUS LAST NAMES________________________________________________________________
SOC. SEC. NUMBER_______-_____-_________ DATE OF BIRTH_____________________________
(DOB IS REQUESTED TO ENSURE ACCURATE RETRIEVAL OF RECORDS.)
CITY AND STATE OF BIRTH______________________________________________________________
DRIVER’S LICENSE NUMBER____________________________________STATE OF ISSUE____________
CURRENT ADDRESS____________________________________________________________________
CITY, STATE, ZIP_______________________________________________________________________
PREVIOUS ADDRESS IF AT ABOVE FOR LESS THAN ONE YEAR: ________________________________
CITY, STATE, ZIP_______________________________________________________________________
APPLICANT’S SIGNATURE______________________________DATE____________________________
***************************************************************************************************
THE COMPANY: ____________________________________________ ___________
REQUESTOR: ___________________ ______________________________ _
RETURN FAX 843-520-0672 OR EMAIL [email protected]
_____CA, MN, OK, and NY applicants only: please check here to have a copy of your consumer report sent directly to you by InfoQuest, Inc
V5.2015
State of South Carolina Release
Worker’s Compensation Commission
I, _________________________________________________ hereby authorize the South Carolina Worker’s
Compensation Commission to provide information in your “Worker’s Compensation Records”
concerning me to Strovis Payroll.
______________________________________________________
Applicant’s Name-printed
_____________________________________
Social Security Number
______________________________________________________
Applicant’s Signature
___________________________________
Date