MDHHH Application for Employment
Email address *
Personal Information
Last Name *
Your answer
First Name *
Your answer
Middle Initial
Your answer
Street Address *
Your answer
City *
Your answer
State *
Zip Code *
Your answer
Date of Available Employment *
MM
/
DD
/
YYYY
Position Applying for *
Type of Work *
Pay Desired *
Your answer
Home Phone *
Your answer
Mobile Phone
Your answer
Driver's License # *
Your answer
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?
Your answer
Approximate Start Date
MM
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DD
/
YYYY
Approximate End Date
MM
/
DD
/
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.
Your answer
If other, please explain.
Your answer
Education and Training
High School Graduate or GED Recipient *
Name of High School (Enter "N/A" if did not graduate) *
Your answer
City and State *
Your answer
Date Graduated/Received GED (Enter "N/A" if neither apply). *
Your answer
Highest level of education completed? *
Name of College/University
Your answer
Graduation/Anticipated Graduation Date
MM
/
DD
/
YYYY
Major
Your answer
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.
Your answer
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.
Your answer
Have you been terminated or asked to resign from any job? *
If Yes, please explain in detail.
Your answer
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).
Your answer
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 *
Your answer
List any other skills or knowledge you have. Enter "N/A" if no additional skills or knowledge. *
Your answer
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).
Your answer
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).
Your answer
Please list all states from which you hold or held driver's licenses. *
Your answer
Employment History
Name of Employer. *
Your answer
Address *
Your answer
City *
Your answer
State *
Phone *
Your answer
Employed from *
Your answer
Employed to *
Your answer
Job Title *
Your answer
Position Worked *
Job Responsibilities *
Your answer
# of Employees Supervised *
Starting Pay *
Your answer
Ending Pay *
Your answer
Reason for Leaving *
Your answer
Supervisor *
Your answer
May we contact? *
If "No," please explain
Your answer
Name of Employer.
Your answer
Address
Your answer
City
Your answer
State
Phone
Your answer
Employed from
Your answer
Employed to
Your answer
Job Title
Your answer
Job Responsibilities
Your answer
# of Employees Supervised
Starting Pay
Your answer
Ending Pay
Your answer
Reason for Leaving
Your answer
Supervisor
Your answer
May we contact?
If "No," please explain
Your answer
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) *
Your answer
2nd Reference: (List Name, Address, Phone, Relationship and Years Acquainted) *
Your answer
3rd Reference: (List Name, Address, Phone, Relationship and Years Acquainted)
Your answer
4th Reference: (List Name, Address, Phone, Relationship and Years Acquainted)
Your answer
Professional Credentials
Please list all professional credentials (include State issued, License Number when applicable. Enter "N/A" if no professional credentials.) *
Your answer
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: *
Your answer
A copy of your responses will be emailed to the address you provided.
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