Specializing in More Good Days


  Contact : 334-347-2999 | Join Our Team

Employment Application

Thank You for applying with DaySpring Hospice and taking time to complete our Employment Application.

At DaySpring Hospice we are an equal opportunity employer and pledge that we will not practice or permit discrimination in employment on the basis of race, color, religion, sex, age, natural origin, citizenship, or disability. This list, however, is not exhaustive of the grounds upon which discrimination is prohibited. We select applicants based on how well their qualifications match the requirements of a particular job we are trying to fill. We look closely at the job-related education, work histories, proven skills and other relevant factors included in this application. Therefore, it is very important to provide us as complete an application as possible.

Please note that this application must be submitted in its entirety and may not be save for future completion. For any questions or concerns, please call 334-347-2999.

    Personal Information

    First Name (required)

    Middle Initial

    Social Security #

    Driver's License #

    Current Address

    Previous Address: (If you have lived less than 7 years in the County listed above, please fill in your previous address below.)

    Previous Address

    Contact Number

    Personal Email

    Do You Have Friends or Relatives Working for LLH?
    YesNo

    If yes, Name

    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?
    YesNo

    If yes, please provide date, city, and state where incident occurred and details of each:


    Employment Desired

    Position you are applying for:

    Start Date

    What type of work are you interested in? (select all that apply)
    Full-Time WorkPart-Time WorkPRNTemporary

    What shifts/hours are you interested in working? (select all that apply)
    DaysEveningsWeekends only10 / 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?
    YesNo

    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.
    YesNo

    Have you ever applied here
    YesNo

    Best time to reach you
    AMPM


    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?
    YesNo

    Please List

    State

    State

    Do you have an application for registration, licensure, or certification pending in the State of Georgia?
    YesNo

    If yes, when do you expect it to be issued?

    Have you ever had a license or registry suspended or revoked?
    YesNo

    If yes, please explain:


    Additional Qualifications (work experience only)

    Please select all that apply

    Clinical / Nursing

    CardiologyIntensive Care Nursery Operating RoomCV LabMedicalDigestive CareMedical CodingOrthopedicsMedical RecordsEmergency/TraumaNeurologyPerformance ImprovementEMTNewborn NurseryPICUGerontologyNursing TechPulmonologyGYNOncologyRecoveryHealth Unit CoordinatorOperating RoomStaff DevelopmentICUSurgicalUroloSurgicalMedical TerminologyUrologyCase Management/Utilization ReviewHospiceHome HealthPediatric

    Office / Special Skills

    Data EntryMedical TerminologyMicrosoft OfficeBilling/InsuranceClerical


    Education History

    Please list schools

    High School

    Last Year Completed


    College

    Last Year Completed


    Graduate School

    Last Year Completed


    Employment History

    Please list present and past employment, beginning with your most recent

    Employer 1

    Employer Name and Address

    Supervisor Name

    Start Date

     

    Reasons for Leaving


    Employer 2

    Employer Name and Address

    Supervisor Name

    Start Date

     

    Reasons for Leaving


    Employer 3

    Employer Name and Address

    Supervisor Name

    Start Date

     

    Reasons for Leaving


    Have You Ever Been terminated from a job?
    YesNo

    If Yes, please explain circumstances

    Please fully explain any gaps in your employment history


    Personal References

    Please do not include former employers or relatives

    Name

    Address

    Name

    Address

    Name

    Address


    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.
    By checking the Box below I agree to reimburse Longleaf Hospice $110.00 if my employment ends voluntarily before the completion of my 90 day probationary period. This amount will be deducted from my final paycheck.

    I Accept


    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 Accept

    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 Accept

    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.

    I Accept

    Furthermore, I understand and agree that:
    a) It is my duty to update and notify LLH of any changes to the information when such changes occur.
    b) If any part of this application is unclear to me, I will ask the Human Resources staff to explain it.
    c) Before my employment becomes effective or compensation is possible, a valid Georgia certification or a proof of eligibility appropriate to my assignment must be filed in LLH’s Human Resources Office.
    d) If offered a position by LLH, I will provide evidence of my right to work as required by the Immigration and Naturalization Service.

    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