MDHHH Application for Employment
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Email *
Personal Information
*
*
Middle Initial
Street Address *
*
State *
Zip Code *
Date of Available Employment *
MM
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DD
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YYYY
Position Applying for *
Type of Work *
Pay Desired *
Home Phone *
Mobile Phone
Driver's License # *
Have you ever been employed with Mid-Delta Home Health and Hospice or any of its affiliates? *
If "Yes", at which office location did you work?
Approximate Start Date
MM
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DD
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YYYY
Approximate End Date
MM
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DD
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YYYY
Do you have any relatives working for Mid-Delta Home Health and Hospice or any of its affiliates? *
Are you a U.S. Citizen? *
How were you referred to Mid-Delta Home Health and Hospice? *
If referred by current employee, please list name.
If other, please explain.
Education and Training
High School Graduate or GED Recipient *
Name of High School (Enter "N/A" if did not graduate) *
City and State *
Date Graduated/Received GED (Enter "N/A" if neither apply). *
Highest level of education completed? *
Name of College/University
Graduation/Anticipated Graduation Date
MM
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DD
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YYYY
Major
Employment Eligibility Information
The Company requires appropriate attendance in your scheduled workday. Can you meet this attendance requirement? *
The Company and their agencies adhere to a smoke-free work place. If hired, will you comply with this policy? *
Have you ever had your professional license, registration or certificate investigated or disciplined by any board or government agency? *
If Yes, please explain in detail.
Have you ever been designated by any board or government agency as an excluded provider for any government reimbursement program? *
If Yes, please explain in detail.
Have you been terminated or asked to resign from any job? *
If Yes, please explain in detail.
Note: A "Yes" answer does not necessarily disqualify you from employment with the Company. Have you ever plead guilty or been convicted of, received probation, or probation with alternative sentence for any crime (misdemeanors or felony), excluding minor traffic violations? *
If Yes, please list (Offense(s), Date, City/State and Sentence or Penalty for each).
SPECIAL SKILLS/KNOWLEDGE
Please select all skills you have: *
Required
List any software applications you are familiar with as related to Home Health Care and Hospice. Enter "N/A" if no additional software experience *
List any other skills or knowledge you have. Enter "N/A" if no additional skills or knowledge. *
Can you speak, read or write any language other than English? *
If "Yes" Please list other languages to which you can Speak, Read or Write).
Do you have access to reliable transportation daily? *
Do you have a valid Driver's License? *
Do you have a valid automobile liability insurance in the amounts of 50,000/100,000/50,000? *
Have you been convicted of or pled guilty to any traffic-related offense within the past five years? *
If Yes, please list (Offense(s), Date, City/State and Sentence or Penalty for each).
Please list all states from which you hold or held driver's licenses. *
Employment History
Name of Employer. *
Address *
City *
State *
Phone *
Employed from *
Employed to *
Job Title *
Position Worked *
Job Responsibilities *
# of Employees Supervised *
Starting Pay *
Ending Pay *
Reason for Leaving *
Supervisor *
May we contact? *
If "No," please explain
Name of Employer.
Address
City
State
Phone
Employed from
Employed to
Job Title
Job Responsibilities
# of Employees Supervised
Clear selection
Starting Pay
Ending Pay
Reason for Leaving
Supervisor
May we contact?
Clear selection
If "No," please explain
References of Character and Work Ethic
Please list at least one character and one work reference
1st Reference: (List Name, Address, Phone, Relationship and Years Acquainted) *
2nd Reference: (List Name, Address, Phone, Relationship and Years Acquainted) *
3rd Reference: (List Name, Address, Phone, Relationship and Years Acquainted)
4th Reference: (List Name, Address, Phone, Relationship and Years Acquainted)
Professional Credentials
Please list all professional credentials (include State issued, License Number when applicable. Enter "N/A" if no professional credentials.) *
Applicant Statement
I verify that the information I have provided in this application (an accompanying resume, if any) is true and complete to the best of my knowledge. I understand that any falsified, misrepresented, incomplete or omitted information may disqualify me from consideration for employment or result in my dismissal from employment when discovered.

I understand that nothing contained in this employment application, or in granting an interview, is intended to create an expressed or implied contract between Mid-Delta Home Health and Hospice and me. No promises regarding my employment or duration of employment have been made to me.

I understand that any offer of employment will be conditional on successful completion of a number of pre-employment requirements, including if applicable a pre-employment drug screening, a health statement (post-offer), verification of credentials and experience, attendance at a general orientation program and any other requirements specified by Mid-Delta Home Health and Hospice. I understand that if any employment relationship is established, either Mid-Delta Home Health and Hospice or I have the right to terminate the relationship at any time for any reason consistent with company policy.

By submitting this application, I authorize Mid-Delta Home Health and Hospice or their representatives to investigate and verify any and all the information contained in the employment application, including criminal background and inquiry into the OIG (Office of Inspector General) sanction list. I also authorize all previous employers, schools, organizations and individuals listed herein to verify any and all information I have provided and to give any additional information in response to reference questions intended to determine my suitability for employment. I hereby release all investigators, previous employers, schools, organizations, individuals and Mid-Delta Home Health and Hospice from any liability for providing or receiving such information.
Typed Signature: *
A copy of your responses will be emailed to the address you provided.
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