Specializing in More Good Days


  Contact : 770-939-9179 | Employment Portal

Job Application

If you’d prefer to download a print ready resume to fill out, please click the button below. Once finished, please email a filled out copy as a file attachment to Terrie.Lang@longleafhospice.com

Download Application

Fields marked with an asterisk (*) must be filled out before submitting.

General Information

First Name *
Middle Initial
Last Name *
Maiden Name
Preferred Name *
Last four of SSN *
Current Address *
City *
County *
State and Zip *
Primary Contact Number *
Alternate Contact Number
Permanent Email Address *
Best Time to Contact You *
How did you hear about the Job? *
Referred by
Have you previously worked for Longleaf? * Yes
No
If yes, dates of employment?
What position?
Have you ever submitted an application to Longleaf Hospice? * Yes
No
If yes, when?

Employment Preferences

Position you are applying for *
Salary Requested *
Date you can start employment *
What type of employment are you interested in? * Full-Time Work
Part-Time Work
PRN
Temporary
What shifts/hours are you interested in working? * Days
Evenings
Weekends only
10/12 hour shift
On occasion, we requrie Clinical Staff to be able to work weekend rotations and on-call rotations and on-call rotations. If you are applying for a clinical position can you work a weekend/on-call rotation schedule? * Yes
No

Record of Educational and Professional Preparation

High School *
Last Year Completed * 9
10
11
12
Did you graduate? * Yes
No
List Diploma or Degree *

College/University *
Last Year Completed * 1
2
3
4
Did you graduate? * Yes
No
List diploma or degree *

College/University
Last Year Completed 1
2
3
4
Did you graduate? Yes
No
List diploma or degree

Other (specify)
Last Year Completed 1
2
3
4
Did you graduate? Yes
No
List Diploma or Degree

License and/or Certification

Are you currently registered, licensed or certified to practice a profession in the state of Georgia? * Yes
No
State
Profession
Number
Expiration Date
 
State
Profession
Number
Expiration Date
 
Do you have an application for registration, licensure, or certification pending in the State of Georgia? * Yes
No
If yes, when do you expect it to be issued?
Do you currently hold a Drivers License from the state of Georgia? * Yes
No
Drivers License #? *
Drivers License State *
Have you ever had your drivers license suspended or revoked in the last three years? * Yes
No
Have you ever had three or more accidents (regardless of fault) in the last three years? * Yes
No
Had three or more moving violations in the last three years? * Yes
No

Additional Information

Subjects of special study/research/work or special training/accomplishments
Clinical/Nursing (check all that apply) Cardiology
Intensive Care Nursery
Operating Room
CV Lab
Medical
Digestive Care
Medical Coding
Orthopedics
Medical Records
Emergency/Trauma
Neurology
Performance Improvement
EMT
Newborn Nursery
PICU
Gerontology
Nursing Tech
Pulmonology
GYN
Oncology
Recovery
Health Unit Coordinator
Operating Room
Staff Development
ICU
Surgical
UroloSurgical
Medical Terminology
Urology
Case Management/Utilization Review
Hospice
Home Health
Pediatric
Other Skills
Office/Special Skills Data Entry
Medical Terminology
Microsoft Office
Billing/Insurance
Clerical
Other Skills

Employment History

Employer 1

Company Name *
Dates of Employment *
Position *
Salary *
Name of Supervisor *
Phone Number *
Reason For Leaving *

Employer 2

Company name *
Dates of Employment *
Position *
Salary *
Name of Supervisor *
Phone number *
Reason for leaving *

Employer 3

Company Name
Dates of Employment
Position
Salary
Name of Supervisor
Phone Number
Reason for leaving

Employer 4

Name of Company
Dates of employment
Position
Salary
Name of Supervisor
Phone Number
Reason for Leaving
I hereby give permission to contact the employers listed above concerning my previous work experience as indicated below
Employer 1 * Yes
No
Employer 2 * Yes
No
Employer 3 Yes
No
Employer 4 Yes
No
Please fully explain any gaps in your employment history

Personal References

Please do not use former employers or relatives
Reference 1 Name *
Reference 1 Phone Number *
Reference 2 Name *
Reference 2 Phone Number *
Reference 3 Name *
Reference 3 Phone Number *

Background Information

*Federal immigration laws (Immigration Reform and Control Act of 1986) require employers to verify and attest to the employment eligibility of new employees to work in the United States. This requirement applies to all applicants. Are you legally authorized to work in the United States? * Yes
No
If you answer “Yes” to any of the questions below, please provide a detailed explanation.
Have you ever been dismissed from a position? * Yes
No
Explain
Have you ever been asked to resign from a position? * Yes
No
Explain
Have you ever been investigated for misconduct related to your employment? * Yes
No
Explain
Are you currently under investigation, or have been charged with any violation of the Georgia Nursing Board’s Code of Ethics or similar professional inquiry in any other state? * Yes
No
Explain
Have you ever had a professional license or certificate (of any kind) revoked or suspended, or have you been placed on probationary status for any alleged misconduct or alleged violation of professional standards or conduct? Are there any pending adverse actions against you? * Yes
No
Explain

Pre-Employment Screening

If I am offered employment by Longleaf Hospice and accept the position I agree that if my employment ends voluntarily before the completion of my 90 day probationary period I will reimburse Longleaf Hospice for the cost of my Pre-Employment Drug Test, Criminal Background Search, and Driving Record Search totaling $110.00.
By selecting this Box, I agree to reimburse Longleaf Hospice $110.00 if my employment ends voluntarily before the completion of my 90 day probationary period. This amount will be deducted from my final paycheck. * I agree

Authorizations

Please read and affirm the below statement

I certify that the information given by me in this application and during the interview process is true and complete to the best of my knowledge and understand that, if employed, falsified or misleading statements may result in my being disqualified from consideration for employment (or subject to immediate dismissal if discovered after I am hired).

I further understand that this application is not intended to be a contract of employment, nor does this application obligate the employer in any way if the employer decides to employ me. I understand and agree that if hired my employment is at-will and can be terminated by me or the company at any time with or without cause. I also understand and agree that no one other than the Vice President of Clinical Operations and another Senior Manager together has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by the Vice President of Clinical Operations and another Senior Manager.

I understand that any offer of employment I may receive will be conditioned on my taking and passing a medical examination given by Longleaf Hospice or its designees, and that the exam may include, but is not limited to, any or all of the following (unless otherwise restricted by law): physical exam, mental exam, and drug screening tests. I understand that if I fail to take such tests or the results are unsatisfactory, I will not be hired by Longleaf Hospice.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

I understand that applications are kept in active status for thirty (30) days so that they may be considered for vacancies during that period. If I wish to be considered for employment after that time, I must reapply.

Confirm Authorizations * I have read and understood the authorizations.
Confirmation Date