Central Wyoming Hospice & Transitions

Please complete the following form to apply for employment at Central Wyoming Hospice & Transitions. All fields are required.

If you prefer to complete a paper application, download the PDF here. Return it to: 319 S Wilson St., Casper, WY 82601

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Personal Information

Name*

First Last

Phone*

Email*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Position Information

Applying for the position of:*

I am seeking:*

Full-time

Part-time

Desired salary:*

How did you find out about this position?*

If offered the position, when would you be available to start?*

Other manner of finding out about position:

Professional Licensure valid in WY?*

Yes

Received from where?*

Have you ever been convicted of a crime?*

If yes, explain in field below.

Yes

Have you received a copy of the job description for this position?*

Yes

Are you physically and mentally able to perform the essential functions of the position for which you are applying?*

Yes

Please describe the previous criminal conviction:*

Employer Statements

Equal Opportunity Employer Statement*

I understand that Central Wyoming Hospice & Transitions is an EQUAL OPPORTUNITY EMPLOYER.

I understand

At-Will Employer Statement*

I understand that my employment with CWHTP is AT-WILL and that my employment can be terminated by me or my employer at any time, without notice, for any reason or no reason at all. I also understand that no person employed by CWHTP is authorized to make any promise or enter into any contract or implement any policy or procedure which states that I will be employed for any definite period of time, states that I cannot be discharged without notice or reason, or states that my employment is other than AT-WILL.

I understand

Education

Institution*

Location*

# Years Attended*

Did you graduate?*

Yes

N/A

Degree(s) Earned*

Occupational History

List most recent employer first. Do not omit any employer.

(1) Employer Name*

Salary*

Supervisor's Name*

Phone*

Address*

Street Address City State ZIP Code

Employment Start Date*

MM slash DD slash YYYY

Employment End Date*

MM slash DD slash YYYY

Describe Job Duties*

Reason for Leaving*

May we contact this employer?*

Yes

(2) Employer Name

Salary

Supervisor's Name

Phone

Address

Street Address City State ZIP Code

Employment Start Date

MM slash DD slash YYYY

Employment End Date

MM slash DD slash YYYY

Describe Job Duties

Reason for Leaving

May we contact this employer?

Yes

(3) Employer Name

Salary

Supervisor's Name

Phone

Address

Street Address City State ZIP Code

Employment Start Date

MM slash DD slash YYYY

Employment End Date

MM slash DD slash YYYY

Describe Job Duties

Reason for Leaving

May we contact this employer?

Yes

(4) Employer Name

Salary

Supervisor's Name

Phone

Address

Street Address City State ZIP Code

Employment Start Date

MM slash DD slash YYYY

Employment End Date

MM slash DD slash YYYY

Describe Job Duties

Reason for Leaving

May we contact this employer?

Yes

(5) Employer Name

Salary

Supervisor's Name

Phone

Address

Street Address City State ZIP Code

Employment Start Date

MM slash DD slash YYYY

Employment End Date

MM slash DD slash YYYY

Describe Job Duties

Reason for Leaving

May we contact this employer?

Yes

Personal References

(1) Full Name*

Address*

City/State/Zip*

Phone*

(2) Full Name*

Address*

City/State/Zip*

Phone*

(3) Full Name*

Address*

City/State/Zip*

Phone*

Acknowledgements

Attending Mandatory Meetings*

I understand that full-time and part-time employees of Central Wyoming Hospice & Transitions Program are required to participate in our Quality Assurance/Performance Improvement Program. Teams meet approximately 1 hour per month.

I understand that Central Wyoming Hospice & Transitions Program employees are required to attend monthly staff meetings. Staff meets approximately 2 hours per month.

I understand

Nursing Applicants*

Central Wyoming Hospice & Transitions Program is a 24/7 facility. While every attempt is made to honor shift preferences to include; straight days, straight nights, weekends & holidays, I understand that I may be assigned to an alternative shift or department if coverage is needed.

I understand

Background Check Authorization

I authorize background checks and investigation of all statements contained in this application. I understand that misrepresentation or omission of facts may be cause for denial of employment or dismissal at a later date. I also authorize pre-employment testing if applicable.*

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Employee Reference "Release of Information"

The below-named person has applied for a position with the Central Wyoming Hospice & Transitions Program. In considering him/her for the position, we are seeking past employment information. The applicant’s signature below releases past employer(s) to provide employment history including but not limited to verification of employment dates, job performance, work habits, skill level and whether the individual is re-hirable.

Name*

First Last

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Signature*

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Date*

MM slash DD slash YYYY