Apply Online

Please complete the following Employment Application and submit it online. You may include your resume via email to jobs@pikespeakhospice.org.

If you prefer, Click Here to download an Employment Application in PDF format. Fax the application and resume to (719) 457-8140.

Applicants are considered for all positions without regard to race, color, religion, gender, national origin, age, sexual orientation, or the presence of a disability, when otherwise qualified.

Date:

Position Applied for:

Referral Source: Please select from drop down list.

If you selected print advertisement, website, or other in the previous box, please list the specific name of the source or website.

Referring PPHPC employee

If you were referred by an employee, please provide his/her name.

___________________________________________________________

Applicant Name

First Name Last Name

Street Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Social Security Number:

Email Address

1. Have you filed an application here before?

2. Have you ever been employed here before?

3. Are you employed now?

4. May we contact your present employer?

5. Are you available to work?

Full Time
Part Time
PRN (as Needed)

6. On what date would you be available for work?

dd/mm/yyyy

7. Are you legally eligible to work in the United States?

(Proof of citizenship or immigration status is required as a condition of employment.)

8. Completion of a formal background check will be a requirement for hire.

Please list employment experience, even if a resume is attached.

Start with your present or last job.

Employer #1:

Phone:

Address:

(Street, City, State, Zip)

___________________________________________________________

Employed From/To:

Job Title:

Immediate Supervisor:

Work Performed:

Starting Hourly Rate/Salary:

Final Hourly Rate/Salary:

Reason for Leaving:

___________________________________________________________________

Employer #2:

Phone:

Address:

(Street, City, State, Zip)

Employed From/To:

Job Title:

Immediate Supervisor:

Work Performed:

Starting Hourly Rate/Salary:

Final Hourly Rate/Salary:

Reason for Leaving:

___________________________________________________________________

Employer #3

Employer #3 Phone

Employer #3 Address

(Street, City, State, Zipe)

Employer #3 Employed From/To

Employer #3 Job Title

Employer #3 Immediate Supervisor

Employer #3 Work Performed

Employer #3 Starting Hourly Rate/Salary

Employer #3 Final Hourly Rate/Salary

Employer #3 Reason for Leaving

___________________________________________________________________

Employer #4:

Employer #4 Phone

Employer #4 Address

(Street, City, State, Zip)

Employer #4 Employed From/To

Employer #4 Job Title

Employer #4 Immediate Supervisor

Employer #4 Work Performed

Employer #4 Starting Hourly Rate/Salary

Employer #4 Final Hourly Rate/Salary

Employer #4 Reason for Leaving

___________________________________________________________________

Professional Reference Check Release

I understand the importance of reference checks into my work background. Therefore, I give permission to, and agree to hold harmless, to release any verbal or written information regarding my work performance to Pikes Peak Hospice & Palliative Care to the following companies:

Reference #1 Name:

Address:

Phone:

___________________________________________________________________

Reference #2 Name:

Address:

Phone:

___________________________________________________________________

Reference #3 Name:

Address:

Phone:

___________________________________________________________________

Typed name constitutes electronic signature

Date:

Name

First Name Last Name

Title of Job Applied For:

Birth Date:

dd/mm/yyyy

Gender:

Male
Female

Voluntary Applicant Information

This form is confidential and will be maintained separately from your application form. It is the Policy of Pikes Peak Hospice & Palliative Care to provide equal employment opportunity to all qualified applicants for employment without regard to race, color, religion, gender, national origin, age, sexual orientation, or the presence of a disability, when otherwise qualified. Various agencies of the government require employers to invite applicants to identify themselves as indicated below. The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis age with respect to individuals who are at least 40 years of age. Completion of this form is voluntary and in no way affects the decision regarding your application for employment.

What is your race/ethnic origin?

Hispanic or Latino—A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
White (Not Hispanic or Latino)
Black or African American (Not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
American Indian or Alaskan Native (Not Hispanic or Latino)
Asian (Not Hispanic or Latino)
Two or More Races (Not Hispanic or Latino)

More information on how you heard about this job:

Employee Rights & Responsibilities Under the Family & Medical Leave Act

Information is available on this site:|www.wagehour.dol.gov.

Apply Online

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Apply Online

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print this page

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Copyright ©2013 pikes peak hospice & palliative care

Website Design by Infront

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