Application | Lighthouse Hospice &

APPLICATION FOR EMPLOYMENT

This company is an Equal Opportunity Employer. We consider all applicants for all positions without regards to race, color, religion, sex, national origin, pregnancy, ancestry, age, marital status, medical condition, physical or mental disability or any other characteristics protected by applicable State and Federal Civil Rights Law.

Last Name, First Name

Professional License No./Expiration Date

Address - Street Address, City, State, Zip Code

Phone

All information will be treated with confidentiality. Please answer all questions as completely as possible. A clear description of your Educational Background and Work History will aid us in evaluating you for a position that best meets our Job Requirements. We appreciate your interest in our Agency and we assure you that we are also interested in your application.

DO YOU HAVE THE LEGAL RIGHT TO WORK AND BE EMPLOYED IN THE UNITED STATES? (Proof of Identity and Legal Authority to work in the U.S. may be required prior to hiring)

Yes

[Please tick the box, if the answer to any of the following is YES]

Have you ever been convicted of a felony offense?

Do you have any arrest with outcomes still pending?

Has your Medical Professional Liability Insurance been denied or cancelled?

Have you ever been involved in any Professional Liability Claims or Litigation?

Has any action ever been taken on your clinical privileges?