Lamoille Home Health and Hospice Online Job Application

Please fill in the information below and press the submit button.

Thank you for your interest in employment with our agency. We consider all applicants for all positions without regard to race, color, religion, sex, national origin, age, sexual orientation, marital or veteran status or disability, or any other legally protected status. The application will remain active for one year. Note: To qualify for employment, you must satisfactorily complete employment interview(s) and test(s) as required. If employment is offered, it will be contingent upon successful completion of a lifiting test, documented proof of the right to work in the United States, any necessary background checks and investigations, verification of previous employment, any sufficient employment references, as well as qualifications for the position, if applicable, such as professional licenses, registration, and/or
certification(s).

PERSONAL INFORMATION

Date of Application
Position Applying For
Referral	Advertisement Friend Relative LHAA Employee Walk In Web Site Dept.of Employ. & Training Other Please specify your referral's name:
Your: First Name
Middle Name
Last Name
Phone
Address
City
State
Zip
Email
Have you filed an application with LHHH before?	No Yes
Have you ever been employed with LHHH before?	No Yes
Are you either a United States citizen or an alien who has the legal right to work in the job for which you are applying? Note: Proof of citizenship or immigration status with employment authorization will be required upon employment.	No Yes
Are you under 16 years of age?	No Yes
Check all that apply to your availability	full-time part-time on call days evenings nights weekends holidays rotation
Have you ever been convicted of a felony?	No Yes
Have you been convicted of a misdemeanor within the past 5 years?	No Yes
Explain here: (Note: A conviction will not necessarily prevent your employment at LHHH or its affiliates.)*
Have you ever been involuntarily discharged from any job?	No Yes
If yes, please explain:
Name any relatives employed by LHHH
DRIVER'S RECORD INFORMATION As part of our hiring and recruiting process, we ask that all applicants complete this section, the purpose of which is to assist LHHH in complying with various internal and external policies and regulations and to protect the safety and well-being of our clients and staff.
Do you currently possess a valid driver’s license?	No Yes State
Do you have the minimum vehicle insurance required by the State of Vermont?	No Yes
If you are hired, are you able to provide LHHH with a certification of insurance?	No Yes
Have you had any violations in the past 8 years (including, but not limited to: DUI/DWI, Careless & Negligent, Accidents, Speeding Tickets, License Suspension/Revocation?	No Yes
If yes, please explain
EDUCATION
High School (Name)
College (Name)
Graduate School (Name)
Vocational or Technical School ( Name)
Other
EMPLOYMENT EXPERIENCE
Must be filled in, with or without resume attached. Give a complete record of all employment and reasons for unemployment during the past 10 years. Most Recent Employer:
Employer Name
Address
City, State, Zip Code
Start Date
End Date
Final Salary
Last Supervisor's Name
Phone
Present or Final Position Title
Position Description
Reason for Leaving
May we contact this employer?	No Yes
Second Employer:
Employer Name
Address
City, State, Zip Code
Start Date
End Date
Final Salary
Last Supervisor's Name
Phone
Final Position Title
Position Description
Reason for Leaving
May we contact this employer?	No Yes
Third Employer
Employer Name
Address
City, State, Zip Code
Start Date
End Date
Final Salary
Last Supervisor's Name
Phone
Final Position Title
Position Description
Reason for Leaving
May we contact this employer?	No Yes
PROFESSIONAL LICENSES, REGISTRATIONS and/or CERTIFICATIONS
Type
Issuing Agency/ State
Effective Dates
Number

Type
Issuing Agency/ State
Effective Dates
Number

Type
Issuing Agency/ State
Effective Dates
Number
REFERENCES Please give us the names of three work-related supervisors who we may contact to verify your qualifications for the position.
Name
Occupation
Organization and Address
Phone

Name
Occupation
Organization and Address
Phone

Name
Occupation
Organization and Address
Phone

CERTIFICATION: I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever. I agree that my employer shall not be liable in any respect if employment is terminated because of the falsity of statements, answers or omissions made by me in this application. I authorize any employers, schools, companies or persons named in this application to give information regarding me and release them from all liability for any damage, both legal and otherwise, from issuing this information. I also agree to abide by the policies and rules of my employer that exist currently or that may be changed or developed in the future, and further realize it is my responsibility to understand such policies. I understand that any employment is not for a stated period of time and may be terminated with or without cause, at any time, at the option of either my employer or myself. Further, I understand that this completed application is the property of Lamoille Home Health & Hospice.
Name
Date