An Equal Opportunity Employer s3

Application for Employment

An Equal Opportunity Employer – Hospice of the Valleys (HOV) is an equal employment opportunity employer and does not discriminate in hiring or employment upon any basis prohibited by law, including race, color, creed, religion, age, sex, national origin, ancestry, sexual orientation, marital status, military status, or disability. None of the questions or information sought in the application is intended to discriminate based upon any status protected by law.

Please Print Name: Last First Middle

Address: Street Address (No P.O. Boxes) City State Zip

Mailing Address (If different): Street Address or P.O. Box City State Zip Home Phone # ( ) - Cell Phone # ( ) - Social Security # E-Mail Address Driver’s License # State Expires EMPLOYMENT DESIRED Position applying for Type of work applying for (check one) Full Time Part Time Per-Diem What days & hours are you available for work – (circle all that applies) Days: Sun Mon Tue Wed Thu Fri Sat Hours: From______am/p To ______am/pm m Are you available for work on weekends? Yes No Would you be able to work overtime if needed? Yes No Salary desired? $ On what date can you start / / work?

PERSONAL INFORMATION Are you currently employed? Yes No If yes, may we contact your current employer? Yes No Are you currently on lay-off or subject to recall? Yes No Have you ever applied to or worked for Hospice of the Valleys (HOV) before? Yes No Do you have any friends or relatives working for HOV? Yes No If yes, state name(s) and relationship: Name Relationship Name Relationship How did you hear about the position? If hired, would you have a reliable means of transportation to and from work? Yes No Certain positions may require use of a vehicle. If use of such vehicle is required Yes No in the job for which you are applying, would there be a problem? Are you willing to travel? Yes No What percentage? % Any restrictions to travel? No local overnight

Are you at least 18 years old? Yes No

Do you have the legal right to work and be employed in The United States? Yes No Prepared for Hospice of the Valleys by Employers Resource Page 1 of 5 Revision 01/01/2018 (Proof of identity and legal authority to work in the U.S. is a condition of employment.)

Do you have a clear understanding of the job duties for the position in which you are applying? Yes No

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? Yes No

If no, describe the functions that cannot be performed

If you require reasonable accommodation(s), please describe any accommodation required

(Note: we comply with the ADA and California Law and provide reasonable accommodation to enable eligible applicants/employees to perform the essential functions of the position.)

Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? (Omit marijuana convictions under California Health and Safety Code §§ 11357 (b) and (c), 1360(c), 11364, 11365 or 11550, or statutory predecessor, that are more than 2 years old.) Yes No

If yes, state nature of the crime(s), when and where convicted, and disposition of the case

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for and any other relevant factors are considered.)

EDUCATION, TRAINING AND EXPERIENCE No. of Did you Degree/ years Major Area of School Name and Address Graduate Diploma Complete Study ? Received d Ye High Name s School City State No Ye Name College/ s University City State No Ye Vocationa Name s l or Business City State No List any other education, specialized training/skills, or certificates/licenses that you might have that relate to this job.

Do you speak, read, write or understand any foreign languages? Yes No If yes, which language(s)?

EMPLOYMENT HISTORY Provide details on your last 7 years of employment and/or last 3 employers (whichever is longer) starting with the most recent employer Note: Attach additional page(s) if necessary. You must complete this section even if attaching a resume. Name of Employer Telephone Number Position Held Supervisor’s Name Street Address City State Zip Date From To Prepared for Hospice of the Valleys by Employers Resource Page 2 of 5 Employed Reason for Leaving May we contact this employer for a reference? Ye N s o

Name of Employer Telephone # Position Held Supervisor’s Name Street Address City State Zip Date Employed From To Reason for Leaving May we contact this employer for a reference? Ye N s o

Prior Employment Continued… Name of Employer Telephone # Position Held Supervisor’s Name Street Address City State Zip Date Employed From To Reason for Leaving May we contact this employer for a reference? Ye N s o

Name of Employer Telephone # Position Held Supervisor’s Name Street Address City State Zip Date Employed From To Reason for Leaving May we contact this employer for a reference? Ye N s o

Please identify and explain all periods of Reason for Unemployment unemployment during the last 10 years: From To

From To

How many days were you absent from work in the past 12 months?

REFERENCES List below three persons not related to you who have knowledge of your work performance within the last three years. Name Telephone # Street Address City State Zip Business Name Occupation No. of Years Acquainted

Name Telephone # Street Address City State Zip Business Name Occupation No. of Years Acquainted

Name Telephone # Street Address City State Zip Prepared for Hospice of the Valleys by Employers Resource Page 3 of 5 Business Name Occupation No. of Years Acquainted

Please read carefully. Initial each paragraph and sign below. Your agreement to the terms below is a condition for consideration of employment with Hospice of the Valleys (the Company). I hereby certify that the answers given by me on this application are true and correct to the best of my knowledge, and that I have not knowingly withheld any information that might adversely affect my chances for employment. I understand that any misstatement or omission of fact on this application or any documents used to obtain employment may result in rejection of this application or immediate discharge if I am employed; regardless of the time elapsed before discovery of the misstatement or omission. I further certify that I, the applicant, have personally completed this application.

Background Check. I hereby authorize the Company to investigate my references, prior employers, work record, education and other matters related to my suitability for employment and further, authorize the references I have listed, all prior employers, and all educational institutions attended, to disclose to the Company any and all letters, reports and other information related to my records, including but not limited to my performance reviews and evaluations, discipline, commendations, awards, and all other employment information, without giving me prior notice of such disclosure. By providing this page of the application to the references, prior employers and educational institutions attended, I release them, to the fullest extent permitted by law, from any and all claims, demands, fees and liabilities for providing the Company with all information, and I release the Company and their agents, employees, clients, or representatives, to the fullest extent permitted by law, from any and all claims, demands, fees and liabilities that may result from any use or disclosure of such information by the Company, or any of their agents, employees, clients, or representatives. I authorize the Company to request and obtain a Consumer Report and/or Investigative Consumer Report, which may include, but is not limited to, criminal, credit and driver’s license, provided state law permits and where such inquiries are job related. (Please refer to and complete the Disclosure and Authorization to Obtain Information form).

Pre-Employment Physical. I understand that a pre-employment physical is required to ensure that employees are capable of performing their essential job-related tasks and to ensure the health and safety of others. The medical evaluations are at the company’s expense and performed by a physician chosen by the company. Hospice of the Valleys will treat as confidential the information contained in a report of medical evaluation. I understand that any offer for employment will be conditional upon the satisfactory results of the pre-employment physical exam.

Drug Testing. Job applicants must submit to a pre-employment drug and alcohol test. Refusal to submit to a drug and alcohol test or a positive confirmed drug and alcohol test may be used as a basis for refusal to hire the applicant. All employees are prohibited from manufacturing, cultivating, distributing, dispensing, possessing or using illegal drugs, alcohol or other unauthorized or mind-altering or intoxicating substances while on company property (including parking areas and grounds), or while otherwise performing their work duties away from the company. Included within this prohibition are alcohol and lawful controlled substances, which have been illegally or improperly obtained. This policy does not prohibit the possession and proper use of lawfully prescribed drugs taken in accordance with the prescription. Employees are also prohibited from having alcohol or any such illegal or unauthorized controlled substances in their system while at work, and from having excessive amounts of otherwise lawful controlled substance in their systems. This policy does not apply to the authorized dispensation, distribution or possession of legal drugs where such activity is a necessary part of an employee’s assigned duties.

At Will Employment. I understand that any employment with the Company is at the mutual consent of the Company and me. Accordingly, either the Company or I may terminate my employment at any time, with or without cause, and with or without notice. I understand that except for the Company’s Executive Director, no employee, representative or agent of the Company has authority to modify the at-will nature of my employment. Any modification of the at-will nature of my employment, or any employment agreement for a specified period of time with the Company, must be set forth in a written agreement signed and dated by the Company’s Executive Director and me. Moreover, nothing conveyed to me, either during any pre-employment interview, or during my employment, if hired, is intended to create an employment contract between the Company and me or to alter the at-will nature of my employment with the Company. In addition, I understand that if hired by the Company this statement shall constitute a final and fully binding integrated agreement with respect to the at-will nature of my employment relationship and that there are no oral or written agreements of any kind contrary to the foregoing.

Arbitration. I hereby agree to submit to binding arbitration all disputes and claims I may have arising out of or related to my applying for employment with the Company, in accordance with the provisions of the “Arbitration of Disputes” policy set forth in the Employment Agreement (and Employee Handbook). I further agree, in the event that I am hired by the Company, that all disputes and claims that I may have that cannot be resolved by informal internal resolution which arise out of or are related to my employment with the Company whether during or after that employment, will be submitted to binding arbitration to the fullest extent permitted by law. I will be given a copy of the Arbitration of Disputes policy as set forth in the Employment Agreement (and Employee Handbook) upon commencement of employment. I agree to read that policy and voluntarily agree to the provisions of that policy in all respects as a condition of my employment.

Auto Insurance. I understand that as a requirement of employment requiring driving, drivers using their own vehicles on company business will be required to show proof of current valid California driver’s licenses and current effective auto insurance. It is the personal responsibility of the vehicle owner to carry adequate insurance coverage for their protection and the protection of any passengers, and the general public. Per the Company’s liability insurance Prepared for Hospice of the Valleys by Employers Resource Page 4 of 5 carrier, all positions that are required to drive on behalf of the Company are required to carry the following vehicle insurance at all times: $10,000 property damage and a minimum of $100,000/$300,000 bodily injury coverage. Drivers are required to provide the Company with a copy of their automobile insurance indicating proof of property and liability coverage prior to employment and ongoing with each policy renewal period. I agree with and consent to all of the above as a condition of employment.

General. I further understand and agree that as a condition to being employed by the Company, I will be required to agree to conduct myself in accordance with the Company’s personnel practices and policies as set forth in the Employee Handbook, a copy of which I will be provided and will review in accepting employment with the Company.

Applicant’s Signature Date

Printed Name

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