HCS Home Healthcare, Hospice and Community Services

- E-Referral
- Referral Information

Fields marked with * are required.

Personal Information
Position Applied for:
* Full Name:
* Address:
* City:
* State:
* Zip:
* Daytime Phone:
Home/Other Phone:
Mobile Phone:
E-Mail Address:
Please list all states, other than New Hampshire, where you have resided during the past five years:
Please list other names under which your records may be found:

Additional Information

How did you hear about this position?

If referred by employee, enter their name:

What is your salary expectation?

When will you be available to begin work?

Years of relevent work experience:

Which job status would you accept?

If part time, how many hours per week?

What days are you available to work?

	Sunday			Monday
	Tuesday			Wednesday
	Thursday			Friday
	Saturday

Have you ever been employed at HCS?

If yes, name at time of employment:

Dates employed:

Position held:

Are you at least 18 years of age?

Are you eligible to work in the United States?

Do you have relatives employed at HCS?

If yes, name?

Have you been convicted of a felony?*
(if sealed or annuled, answer no)

Have you been convicted of a misdemeanor?*
(if sealed or annuled, answer no)

* A conviction will not necessarily be a bar to employment. Factors such as age when the offenses occured, the relentlessness of the offense, the seriousness and nature of the violation, the nature of the position applied for, and any rehabilitiation undergone may be taken into account.

High School
School, City, State, Zip (if known)
Major(s):
Did you graduate (or receive GED)?
Course of Study:
Diploma or Degree:
Number of Years Completed:
Vocational/Trade/Technical School
School, City, State, Zip (if known)
Major(s):
Did you graduate (or receive GED)?
Course of Study:
Diploma or Degree:
Number of Years Completed:
College/University (Undergraduate)
School, City, State, Zip (if known)
Major(s):
Did you graduate (or receive GED)?
Course of Study:
Diploma or Degree:
Number of Years Completed:
College/University (Graduate)
School, City, State, Zip (if known)
Major(s):
Did you graduate (or receive GED)?
Course of Study:
Diploma or Degree:
Number of Years Completed:
Other Educational Institution
School, City, State, Zip (if known)
Major(s):
Did you graduate (or receive GED)?
Course of Study:
Diploma or Degree:
Number of Years Completed:

License/Certification/Registrations Held
License/Certification
State
License Number:
Issued:
Expires:
Temporary or Permanent?

License/Certification
State
License Number:
Issued:
Expires:
Temporary or Permanent?

License/Certification
State
License Number:
Issued:
Expires:
Temporary or Permanent?

License/Certification
State
License Number:
Issued:
Expires:
Temporary or Permanent?

Current CPR Card?
Has your license/certification ever been revoked? If so, please explain:
Job skills and/or other relevent training:

References
Reference
Company
Relationship
Phone
Years Known

Reference
Company
Relationship
Phone
Years Known

Reference
Company
Relationship
Phone
Years Known

Work History If you do not have additional work history, you may leave the remaining questions blank.
Company Name
Address
City
State
Zip
Type of Business
Phone
Other Name Used
Job Title
Dates Employed		to
Starting Salary
Ending Salary
Supervisor
Job Duties/Responsibilities
Reason for Leaving
May we contact?
Status

Company Name
Address
City
State
Zip
Type of Business
Phone
Other Name Used
Job Title
Dates Employed		to
Starting Salary
Ending Salary
Supervisor
Job Duties/Responsibilities
Reason for Leaving
May we contact?
Status

Company Name
Address
City
State
Zip
Type of Business
Phone
Other Name Used
Job Title
Dates Employed		to
Starting Salary
Ending Salary
Supervisor
Job Duties/Responsibilities
Reason for Leaving
May we contact?
Status

Company Name
Address
City
State
Zip
Type of Business
Phone
Other Name Used
Job Title
Dates Employed		to
Starting Salary
Ending Salary
Supervisor
Job Duties/Responsibilities
Reason for Leaving
May we contact?
Status

Do you have any gaps in your employment?

Yes

If yes, please explain:

In the past, have you been terminated or asked to leave a position?

Yes

If yes, please explain:

Cover Letter and Resume
To cut and paste your cover letter and/or resume:

Highlight the text on the cover letter or resume you want to copy.
Press "Ctrl C" to copy (hold down the Ctrl key and press C).
Place the cursor in the COVER LETTER or RESUME box below.
Press "Ctrl V" to paste the information (hold down the Ctrl key and press V).

COVER LETTER

RESUME

Applicant Voluntary Invitation for Self-Identification
Home Healthcare, Hospice & Community Services is an Equal Opportunity Employer, and does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, national origin, disability, veteran status or any other classification protected by federal, state or local law. As a federal contractor, we comply with all relevant governmental regulations and affirmative action responsibilities. In order to assist us with record-keeping, reporting and other legal requirements, we offer you the opportunity to complete this self-identification form. Please know that submission of this information is entirely voluntary. Providing this information or declining to do so will have no bearing on your employment with HCS. We value diversity and encourage women and minorities to join our workforce. We appreciate your help in assisting us with our affirmative action efforts.

Sex

Male

Female

Race/Ethnic Group

	Hispanic or Latino
	Black/African American
	White
	Native Hawaiian or Other Pacific Islander
	Asian
	American Indian or Alaskan Native
	Two or More Races (not Hispanic or Latino)

Home Healthcare, Hospice and Community Services (HCS) is Medicare certified, and licensed by the State of New Hampshire. HCS programs are provided to all service eligible individuals without regard to age, race, religion, sex, handicapping conditions, marital or economic status, except where constrained by specialized funding. HCS is a United Way Agency.