Have you ever pled guilty or “no contest” to a crime, been convicted of a crime, had adjudication withheld, prosecution deferred or do you have any criminal charges pending?
Yes No
If yes, please provide date, city, and state where incident occurred and details of each:
Employment Desired
What type of work are you interested in? (select all that apply)
Full-Time Work Part-Time Work PRN Temporary
What shifts/hours are you interested in working? (select all that apply)
Days Evenings Weekends only 10 / 12 hour shift
We require Clinical Staff to be able to work weekend rotations and on-call rotations. If you are applying for a clinical position can you work a weekend/on-call rotation schedule?Yes No
Are you legally eligible for employment in the USA? If hired, you are required to submit proof of your eligibility to work in the USA.
Yes No
Have you ever applied here
Yes No
Best time to reach you
AM PM
General Information
Subjects of Special Study/Research/Work or Special Training/Accomplishments:
License and/or Certification
Are you currently registered, licensed, or certified to practice a profession in the state of Georgia?
Yes No
Please List
Do you have an application for registration, licensure, or certification pending in the State of Georgia?
Yes No
If yes, when do you expect it to be issued?
Have you ever had a license or registry suspended or revoked?
Yes No
If yes, please explain:
Additional Qualifications (work experience only)
Please select all that apply
Clinical / Nursing
Cardiology Intensive Care Nursery Operating Room CV Lab Medical Digestive Care Medical Coding Orthopedics Medical Records Emergency/Trauma Neurology Performance Improvement EMT Newborn Nursery PICU Gerontology Nursing Tech Pulmonology GYN Oncology Recovery Health Unit Coordinator Operating Room Staff Development ICU Surgical UroloSurgical Medical Terminology Urology Case Management/Utilization Review Hospice Home Health Pediatric
Office / Special Skills
Data Entry Medical Terminology Microsoft Office Billing/Insurance Clerical
Education History
Please list schools
Last Year Completed
9 10 11 12
Last Year Completed
fr so jr sr
Last Year Completed
1 2 3 3+
Employment History
Please list present and past employment, beginning with your most recent
Employer 1
Reasons for Leaving
Employer 2
Reasons for Leaving
Employer 3
Reasons for Leaving
Have You Ever Been terminated from a job?
Yes No
If Yes, please explain circumstances
Please fully explain any gaps in your employment history
Personal References
Please do not include former employers or relatives
Pre-Employment Screening
If I am offered employment by Longleaf Hospice and accept the position I agree that if my employment ends voluntarily before the completion of my 90 day probationary period I will reimburse Longleaf Hospice for the cost of my Pre-Employment Drug Test, Criminal Background Search, and Driving Record Search totaling $110.00.
Verification and Authorizations
Longleaf Hospice (LLH) does not discriminate on the basis of age, race, color, sex, sexual orientation, religious preference, marital status, disability, national origin, or any other reason prohibited by state or federal law. I understand that complete applications are kept active for sixty (60) days so that they may be considered for vacancies during that period. If I wish to be considered for employment after that time, I must reapply.
CERTIFICATION OF APPLICATION: Please read the following statements carefully and check the boxes as confirmation of your having read and accepted these conditions of employment if a position is offered to you.
I hereby certify that all information provided by me on this employment application and all other information provided by me in the course of applying for employment at Longleaf Hospice, LLC ("LLH") is truthful, accurate, and complete. I understand that if any information provided by me on this employment application or any other information provided by me in the course of applying for employment at LLH is found to be false, untruthful, misleading, or incomplete that such will be cause for immediate rejection of my application for employment. I further understand that if I am hired as an employee of LLH and at any time thereafter it is discovered that any information provided by me on this employment application or any other information provided by me in the course of applying for employment at LLH is found to be false, untruthful, misleading, or incomplete, that shall be sufficient cause for disqualification or dismissal from employment.
I understand that an offer of employment I may receive will be conditioned on my taking and passing a medical examination given by Longleaf Hospice or its designees, and that the exam may include, but is not limited to, any or all of the following (unless otherwise restricted by law): physical exam, mental exam, and drug screening tests. I understand that if I fail to take such tests or the results are unsatisfactory, I will not be hired by Longleaf Hospice. A photocopy of this release will be valid as an original even though the photocopy does not contain an original writing of my signature. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.
I hereby authorize LLH to obtain information relating to my current and previous employment, education, personal history records and criminal history records. I agree to release LLH, its employees, representatives, and agents from any and all liability claims or damages for the obtaining and use of information obtained from these sources or developed as a result of contacting these sources.
Furthermore, I understand and agree that:
By clicking the "Submit” button, my application will be submitted to Longleaf Hospice, LLC as an application for employment. I further understand and agree that my act of electronically submitting this application constitutes my electronic signature.
I Accept
