Employment Application - GHI

Galaxy Hospice, Inc.
ONLINE APPLICATION

Application Date: * +

Position Desired: *

Employment Availability: *

Full-Time

Part-Time

Per Diem

Shift Desired: *

Day

Evenings

Nights

APPLICANT INFORMATION

First Name *

Last Name *

MI.

Name used in the past (if applicable):

Gender: *

Male

Female

Street Address *

House/Apartment No:

City *

State *

Zip Code *

Phone Number *

Mobile Phone

Email Address *

Questions: *

	Yes	No
Are you 18 or older?	Yes	No
Do you have reliable means of transportation to get to and from work?	Yes	No
Can you submit verification of your legal right to work in the United States?	Yes	No
Do you have any physical condition that would substantially interfere your ability to perform the duties of the job?	Yes	No
Have you ever been employed with Galaxy Hospice before?	Yes	No
Have you ever applied with Galaxy Hospice, Inc before?	Yes	No
Have you ever been convicted of a crime in the last 7 years? If yes, please explain:	Yes	No
Can you lift at least 25 pounds or more? If no, please explain:	Yes	No

Explanation: (If Applicable)