Applicants Name*

 

Job Applying For*

 

    Upload your resume
    *

     

    Address

    City

    State

    ZIP

     

    Home Phone

    Cell Phone*

    Your Email Address*

    Major Cross Streets

     

    Are you legally eligible to work in the United States?

    Please list three (3) personal references that are not related to you

     

    Reference 1

    Name

    Phone

    Relationship

    Years Known

    Address

     

    Reference 2

    Name

    Phone

    Relationship

    Years Known

    Address

     

    Reference 3

    Name

    Phone

    Relationship

    Years Known

    Address

     

    7. Do you possess a valid driver's license?

    State of Issue & License Number

     

    8. Has your driver�s license even been suspended or revoked?

     

    9. Have you ever been convicted of a felony?

     

    If yes, please explain

     

    10. Have you ever had a license to provide health care revoked, limited, modified,
    or suspended?

     

    11. Have you ever had any disciplinary action taken against your license to provide

    health care?

     

    12. Have you ever had any criminal conviction relating to:

    a) Any federal health care program including Medicare and Medicaid?

     

    b) Patient neglect or abuse?

     

    c) Healthcare fraud?

     

    d) Use of a controlled substance?

     

    e) Fraud, theft, embezzelment?

     

    f) Breach of fiduciary responsibility or other financial misconduct?

     

    g) Obstruction to a health care investigation?

     

    PLEASE READ
    The facts set forth in my volunteer application are true and complete. I understand that if accepted in a volunteer role, false statements or omissions on this application will usually result in revocation of my volunteer status.

     

    Permission is herby given to the Company to investigate previous employment, educational background and references. I release the Company and former employers from any liability resulting from any lawful information provided which may result in termination of my volunteer status.

     

    I understand that the Company has a policy requiring that a background check be completed on all volunteers, and will be done upon completion of the Volunteer Training Program at no cost to me. I agree to provide any additional information necessary to complete the background check.

     

    I understand that the Company has a policy prohibiting conflicts of interest or improper use of proprietary information which prohibits any release or use of Company property that would interfere with the business interests or operations of the Company. I understand that my volunteer status may be terminated at any time by either the Company or myself with or without cause.

     


    Infinity Hospice Foundation

    The Infinity Hospice Foundation is a non-profit organization dedicated to providing education to Physicians, caregivers and family members of the terminally ill regarding hospice and palliative care.

     

    READ MORE ABOUT IHF

    Home Care Services

    Infinity Hospice Care enhances the quality of a patient�s life

    LEARN MORE

    Make a Referral

    Medical treatment decisions are a matter of personal choice

     

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