Employment Application

At Serenity First, we invest in our team members. We offer competitive compensation, ongoing training, and a culture built on respect and support. Find your Virginia hospice job today!

Personal Information

Legal Last Name *

Legal First Name *

Date of birth

May We Contact You Via EmailYesNo

If yes, please provide email address

Home Phone Number

Date available to start work *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Country

Mobile phone number *

Were you previously employed by Serenity First LLC?YesNo

If YES, Date: From

If NO, how were you referred?

Are you at leas 18 years of age? *YesNo (if less than 18 years, you may need to provide a work permit and/or work release upon offer of employment dependent on state and local regulations)

Job Interest

Wage/Salary desired: $ *

USD

Select

Position for which you are applying *

Location

Preferred Work Schedule

Hours of availability

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Education Information

Type of School

Name and Location

Years Completed

Major Course of Study

Graduated

Degree

Job Related Skills or Experience

List any job-related skills or experience that would qualify you for the position for which you are applying:

Starting with your most recent job, accurately list ALL jobs you have held in the past ten (10) years. Give correct addresses and telephone numbers. Include volunteer experience.

1. Name of current/most recent employer: *

Position Held *

Employer's email address:

Phone Number

Date Employed: From *

To *

May we contact this employer *YesNo

Reason for leaving *

Supervisor (name and title) *

2. Name of next most recent employer *

Position Held *

Employer's email address:

Phone Number

Date Employed: From *

To *

May we contact this employer *YesNo

Reason for leaving *

Supervisor (name and title) *

3. Name of next most recent employer

Position Held

Employer's email address:

Phone Number

Date Employed: From

May we contact this employerYesNo

Reason for leaving

Supervisor (name and title)

References

Please provide the names, addresses, and telephone numbers of at least two (2) professional references who are not related to you.

1. Name

Title

Email address

Telephone number

2. Name

Title

Email address

Telephone number

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING BELOW

We greatly appreciate your interest in our organization. Please be advised that applicants are considered for all positions without regard to race, color, religion sex, age, sexual orientation, gender identity, national origin, disability or any other protected characteristics as established by law. This policy of Equal Employment Opportunity applies to all policies and procedures relating to recruitment and hiring, compensation, benefits, termination and all other terms and conditions of employment. For consideration of employment with us, the application must be completed in its entirety and signed by you. This application will remain open for consideration for this position for which you applied for ninety (90) days from today's date. If you wish to be considered for this position or another position after ninety days from this date, you will need to complete and submit another application. Should you be formally offered a position with Serenity First LLC, your employment will be considered "at will", which means that there us no agreement between you and Serenity First LLC or any of its affiliated companies for any definite period of employment. Furthermore, it is understood that you or Serenity First LLC has the right to terminate your employment at any time, with or without cause. There is no guarantee of employment terms, conditions or benefits except those that are made in writing by the owner or authorized executive level manager.

I certify that the answers given by me are true and correct without omissions of any kind whatsoever, and that intentional falsification of information given will be grounds for disciplinary action, up to and including termination.

I understand that if hired, the employment relationship is at-will. This means that either Serenity First LLC or I may terminate the employment relationship at any time for any or no reason.

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Signature of Applicant *

Todays Date *

Serenity First LLC IS AN EQUAL OPPORTUNITY EMPLOYER

DIVISION OF LICENSING PROGRAMS SWORN DISCLOSURE STATEMENT

To the Applicant: Section 63.2-1720 of the Code of Virginia requires that any person desiring work at a licensed assisted living facility or licensed adult day care center provides the hiring facility or center with a sworn disclosure statement or affirmation disclosing any criminal convictions or pending criminal charges, whether within or outside the Commonwealth of Virginia. The law prohibits licensed assisted living facilities and licensed adult day care centers from hiring any individuals convicted of a barrier crime (specified below). However, applicants convicted of one misdemeanor barrier crime not involving abuse or neglect may be hired if five years have elapsed since the conviction. Any person making a false statement on this form regarding any criminal offense shall be guilty of a Class 1 misdemeanor. Further dissemination of the information provided on this form is prohibited other than to the Commissioner's representative or a federal or state authority or court as may be required to comply with an express requirement of the law for such further dissemination.

1. Last Name

First

Middle

last 4 SSN

Street/P.O. Box

City

State

Zip

Have you ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that was finally adjudicated in a juvenile court or under a youth offender law? *YesNo

If yes, list all and explain:

3. Are you the subject of any pending criminal charges? *YesNo

If yes, list all and explain:

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Signature of Applicant: *

Date Today *

NOTE TO LICENSEE: This form must be retained for a􀂏􀂏 compensated employees.

BACKGROUND AUTHORIZATION

I understand and agree that submitting this application form does not automatically qualify me as an employee, and that there are certain requirements I must meet prior to employment being offered. I authorize Serenity First LLC Services to contact the two references listed on my application, and have included COMPLETE contact information for both of them. I understand that prior any employment, I will be required to complete and successfully pass a Criminal Background/Sex-Offender History verification. By checking the “I AGREE" box below, l attest that the information I provided on this application is true and accurate.

I agree

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Signature of Applicant: *

Date Today *