Connecticut Hospice Job Application - Page 1 of 5
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Position/s Applied For
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Date of Application
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How did you learn about us?
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Website
Relative
Friend
Inquiry
Other
If Other please describe.
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Last Name
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First Name
Middle Name
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Street Address
Address Line 2
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City
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State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
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Zip Code
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Phone Number
Social Security
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Email Address
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Best time to contact you at home is:
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If you are under 18 years of age, can you provide required proof of your eligibility to work?
Yes
No
N/A
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Have you ever filed an application with us before?
Yes
No
If yes, give date.
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Have you ever been employed with us before?
Yes
No
If Yes, give date.
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Do any of your friends or relatives, other than spouse, work here?
Yes
No
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Are you currently employed?
Yes
No
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May we contact your present employer?
Yes
No
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Are you prevented from becoming lawfully employed in this country because of Visa or Immigration Status?
Proof of citizenship or immigration status will be required upon employment
Yes
No
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Date available for work
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What is your desired salary range?
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Are you available for work:
Full Time
Part Time
Temporary
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(Please indicate shift)
1
2
3
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(Please indicate)
mornings
afternoons
evenings
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Are you currently on "lay-off" status and subject to recall?
Yes
No
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Can you travel if your job requires it?
Yes
No
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