Career Application

Last Name

required

First Name

required

Middle

required

Address: No. & Street

required

City

required

State

required

Zip Code

required

Cell Phone

required

Home Phone

E-mail Address

required

Employment Desired:

Position Applying For:

required

Are you applying for:

required

Availability

Days
Evenings
Nights
Weekends

Check all that Apply

What days are you available for work

required

What hours are you available for work?

required

Are you available to work on the weekends

yes
no

required

Would you be available to work overtime, if necessary?

yes
no

required

If hired, what date can you start work?

required

Personal Information

How did you hear about our company and this job opening?

required

Have you ever applied to or worked for LightBridge Hospice before?

yes
no

required

If you have applied before, when?

Why are you applying for work at LightBridge Hospice?

required

Do you have a valid driver's license?

yes
no

required

License #

Proof of auto insurance is required as a condition of employment.

State Issued In:

If hired, would you have a reliable means of transportation to and from work?

yes
no

required

Are you legally eligible to work in the United States?

yes
no

Proof of eligibility is required as a condition of employment.

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

yes
no

required

If yes, please explain:

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?

yes
no

required

If no, describe the functions that cannot be performed:

Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants / employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.

Have you ever been or are you currently excluded, debarred, suspended from or otherwise ineligible to participate in Medicare, Medi-Cal, or any other federal or state funded healthcare programs?

yes
no

required

Please list any friends or family members currently employed by LightBridge Hospice:

We may refuse to hire relatives of present employees if doing so could result in actual or potential problems in supervision, security, safety, or morale, or if doing so could create conflicts of interest.

Education, Training and Experience

High School

High School Name

Address

City

State

Zip Code

Did you graduate?

yes
no

Degree or Diploma

College/University

College/University Name

Address

City

State

Zip Code

No. of Years Completed

Did you Graduate?

yes
no

Degree or Diploma

Vocational Business School

Vocational Business School Name

Address

City

State

Zip Code

No. of Years Completed

Did you graduate?

yes
no

Degree or Diploma

Health Care Training

Health Care Training Name

Address

City

State

Zip Code

No. of Years Completed

Did you graduate?

yes
no

Degree or Diploma

Do you have any other experience, training, qualifications, or skills that you feel make you especially suited for work at LightBridge Hospice?

yes
no

required

If yes, please explain:

Some of our patients or their family members may not speak English fluently. Do you speak any language besides English that may assist family members?

yes
no

required

If yes, what language(s)

Answer the following questions if you are applying for a professional position:

Are you licensed/certified for the job applied for?

yes
no

required

Name of license/certification

Issuing State

License/certification number:

Has your license/certification ever been revoked or suspended?

yes
no

required

if yes, state reason(s), date of revocation or suspension, and date of reinstatement.

Employment History

Answer the following questions if you are applying for a professional position:

#1 Name of Employer

Employer Phone Number

Type of Business

Your Supervisor's Name

Address & Street

City

State

Zip Code

Your Position and Duties

Reason for Leaving

Is this your current employer?

yes
no

Dates of Employment

May we contact this employer for a reference?

yes
no

#2 Name of Employer

Employer Phone Number

Type of Business

Your Supervisor's Name

Address & Street

City

State

Zip Code

Your Position and Duties

Reason for Leaving

Dates of Employment

May we contact this employer for a reference?

yes
no

#3 Name of Employer

Employer Phone Number

Type of Business

Your Supervisor's Name

Address & Street

City

State

Zip Code

Your Position and Duties

Reason for Leaving

Dates of Employment

May we contact this employer for a reference?

yes
no

#4 Name of Employer

Employer Phone Number

Type of Business

Your Supervisors Name

Address & Street

City

State

Zip Code

Your Position and Duties

Reason for Leaving

Dates of Employment

May we contact this employer for a reference?

yes
no

References

List below three persons not related to you who have knowledge of your work performance within the last three years.

#1 Reference: First Name

required

Last Name

required

Phone

required

Address & Street

required

City

required

State

required

Zip Code

required

Occupation

required

No. of Years Acquainted

required

Work Relationship

required

#2 Reference: First Name

required

Last Name

required

Phone

required

Address & Street

required

City

required

State

required

Zip Code

required

Occupation

required

No. of Years Acquainted

required

Work Relationship

required

#3 Reference: First Name

required

Last Name

required

Phone

required

Address & Street

required

City

required

State

required

Zip Code

required

Occupation

required

No. of Years Acquainted

required

Work Relationship

required

Please Read Carefully

The Company will consider qualified applicants in a manner consistent with state and local "Fair Chance" laws.

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

required

I hereby authorize LightBridge Hospice to thoroughly investigate my references, work record, education and other matters related to my suitability for employment (excluding criminal background information) unless otherwise specified above. I further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure

required

I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Company's designated representative.

required

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

required

Date

required

Career Application

To Apply: