Fill and Sign the Employment Health Care Form

EMPLOYMENT APPLICATION DATE: ________________________ If you need help in completing this application, please request assistance. (e.g., use initials of Health Care Organization) _________________ refers to _____________________________________________________ (Name of Health Care Organization) . _________________ (HCO) complies with all applicable laws concerning hiring and employment practices and is firmly committed to maintaining a workplace free from unlawful discrimination. We strive to provide equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, or military status in accordance with applicable federal and state laws. PLEASE PRINT LEGIBLY IN INK - In addition to completing this application, please submit your resume’ on-line at ___________________________________________ (website of HCO) . PERSONAL INFORMATION Please write your name below as it appears on your social security card: ____________________________ ___________________________________________________________ Social Security Number: __________________________________________________ Present Address (City/Town State Zip Code): _______________________________________________ ____________________________________________________________________________________ Permanent Address (If Different): _________________________________________________________ _____________________________________________________________________________________ Home Telephone Number: _______________________ Work Telephone Number: _____________________ Cell Phone Number: ___________________________ E-mail Address: __________________________ Position for Which You are Applying: _______________________________________________________ Availability: ( ) Full Time ( ) Part Time ( ) Temporary ( ) Internship ( ) Evenings ( ) Weekends ( ) Other (Explain)____________________________________________ Work Location Preference(s): ____________________________________________________________ ______________________________________________________________________________________ Are you currently authorized to work in the United States: ( ) yes ( ) no Do you now, or will you in the future, require sponsorship for a work visa? ( ) yes ( ) no Are you over 18 years of age? ( ) yes ( ) no If no, when will you turn 18? ________________ Have you ever been employed by ______________ (HCO) ? ( ) yes ( ) no If you have been previously employed by _______________ (HCO) , please specify the following: From _______________ to _______________ Department _________________ Position ________________ 1 Location _______________________ Supervisor __________________________________ Names of any relatives employed by ________________ (HCO) : Name: _________________________________ Department ________________ Relationship ____________ Name: _________________________________ Department ________________ Relationship How did you hear about employment opportunities with _____________ (HCO) ? ( ) Employment Agency ( ) Job Fair ( ) ______________ (HCO) Website ( ) Advertisement ( ) Employee Referral ( ) Direct Recruitment ( ) Other __________________________ PRIOR WORK, MILITARY AND VOLUNTEER EXPERIENCE In order that we may verify prior experience, have you used another name in your previous jobs? ( ) No ( ) Yes, give name and specify organization(s) ____________________________________ __________________________________________________________________________________________ List most recent experience first. Please include volunteer experience. 1. Name of Organization ___________________________________________________________________ Street Address, City, State, Zip Code _________________________________________________________ _________________________________________________________________________________________ Title or Position ___________________________ Name of Supervisor ______________________________ Duties ___________________________________ Annual Salary or Hourly Rate _____________________ Dates Employed, From _________ until ________________. Reason for Leaving______________________ __________________________________ Can we contact Organization for reference? ( ) Yes ( ) No 2. Name of Organization ___________________________________________________________________ Street Address, City, State, Zip Code _________________________________________________________ _________________________________________________________________________________________ Title or Position ___________________________ Name of Supervisor ______________________________ Duties ___________________________________ Annual Salary or Hourly Rate _____________________ Dates Employed, From _________ until ________________. Reason for Leaving______________________ 2 __________________________________ Can we contact Organization for reference? ( ) Yes ( ) No 3. Name of Organization ___________________________________________________________________ Street Address, City, State, Zip Code _________________________________________________________ _________________________________________________________________________________________ Title or Position ___________________________ Name of Supervisor ______________________________ Duties ___________________________________ Annual Salary or Hourly Rate _____________________ Dates Employed, From _________ until ________________. Reason for Leaving______________________ __________________________________ Can we contact Organization for reference? ( ) Yes ( ) No REFERENCES In addition to current and form employers, please list two additional professional references below that we may contact: Name ________________________________Relationship ______________ How long know,? __________ Company ____________________________ Title _________________ Daytime Phone No. ______________ Evening Phone No. ___________________ E-mail ___________________________ Address (Street Address, City, State, Zip Code) _________________________________________________ __________________________________________________________________________________________ Name ________________________________Relationship ______________ How long know,? __________ Company ____________________________ Title _________________ Daytime Phone No. ______________ Evening Phone No. ___________________ E-mail ___________________________ Address (Street Address, City, State, Zip Code) _________________________________________________ __________________________________________________________________________________________ EDUCATION Name of High School __________________________________ Graduate ( ) Yes ( ) No Address (Street Address, City, State, Zip Code) _________________________________________________ __________________________________________________________________________________________ Name of College _____________________________________________ Graduate ( ) Yes ( ) No 3 Address (Street Address, City, State, Zip Code) ____________________________________________ _________________________________________________________________________________________ Type of Degree _________ Year ____________ Major ____________ Minor _____________ Other -- Name of School __________________________________ Graduated ( ) Yes ( ) No Address (Street Address, City, State, Zip Code) _________________________________________________ __________________________________________________________________________________________ Type of Degree or Certificate ______________ Year _____________________ Major ____________ PROFESSIONAL LICENSES, REGISTRATIONS, AND CERTIFICATES Type of License Reg. No. Expiration Date State or Certificate ______________________________ __________________ _______________ _________________ ______________________________ __________________ _______________ _________________ ______________________________ __________________ _______________ _________________ Describe your working knowledge of computer software _______________________________________ _________________________________________________________________________________________ CRIMINAL RECORD Please complete this section on prior convictions. An applicant for employment with a sealed record on file with a court (such as a juvenile record) may answer “no record” with respect to an inquiry relative to prior arrests, criminal court appearances or convictions. A criminal arrest or conviction will not necessarily be a bar to employment. 1. Have you been convicted of a misdemeanor (excluding a first conviction for speeding or minor traffic violations) within the last five years? ( ) Yes ( ) No 2. Have you ever been convicted of a felony? ( ) Yes ( ) No If you have answered yes to either of the above questions, please provide an explanation below. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 4 PLEASE READ BEFORE SIGNING I certify that all answers and statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing which, if disclosed, might affect this application unfavorably. I understand that any falsification, misrepresentation or material omission of information submitted on this application will constitute grounds for denial or immediate dismissal from employment. I authorize all persons, schools, employers and other organizations mentioned in this application to provide ___________ (HCO) with any and all information requested by __________ (HCO) related to my qualifications for employment. I hereby voluntarily release ____________ (HCO) and any other persons or entities from any and all liability related to the provision of such information. I further understand that any job offer will be contingent upon satisfactory replies to background and reference checks and that information about the content and scope of such checks will be furnished to me if I make a written request for such information within a reasonable time. I further understand that employment with __________ (HCO) may be conditioned upon the results of a medical screening examination, skills testing and my ability to provide satisfactory documentation of my U.S. citizenship or authorization to work in the U.S. within 72 hours of the commencement of my employment. I understand that nothing in this application for employment is intended or should be construed as an offer, agreement or contract of employment. I further understand that employment at ___________ (HCO) is at-will, which means that both the employer and the employee are free to terminate the employment relationship at any time, with or without notice or cause. In the event that I am employed by ____________ (HCO) , I agree to comply with all of its employment policies. HCO reserves the right to change or amend policies from time to time. No supervisor, representative or other person at ___________ (HCO) has the authority to make any agreement that is contrary to the foregoing without the written approval of _____________ (HCO’s) _____________________________________________________ (Name of Office such as Vice President of Human Resources) . This information provided to ________________ (HCO) is considered current for one year only. At the end of this period, if you are still interested in employment, it will be necessary for you to reapply by filling out a new application. Signature of Applicant _______________________________________ Date __________________ 5 Print Name: _______________________________________ ______ Important Information About the Application Process Thank you for your interest in employment with _______________ (HCO) . The following is information on some of the steps in the employment process: 1. The Employment Application. All applicants for employment with ________________ (HCO) must complete the ____________ (HCO) Employment Application. Even if you submit a resume to ____________ (HCO) , we still require a completed Employment Application. The Employment Application gathers information on education and training, prior work experience, prior criminal convictions, and references you authorize us to contact. If you are hired by _______________ (HCO) , the Employment Application will become part of your personnel file. 2. Background Checks on Final Candidates. _______________ (HCO) conducts certain background checks on final candidates prior to an offer of employment. In rare cases where there is a business need for a final candidate to begin employment immediately, _______________ ( HCO) may make an offer of employment subject to satisfactory results on the background checks. ______________ ( HCO) requires specific written authorization to conduct background checks relative to credit history and prior criminal convictions. If you do not authorize ________________ ( HCO) to perform a background check, we will no longer consider your application for employment. If _____________ ( HCO) has conducted a background check on you within the past six months and you apply for a new ______________ ( HCO) position, we will not require a new background review. 3. Prior Felony Conviction Relative to a Crime of Dishonesty or a Breach of Trust. In general, a finding that an applicant has a criminal record is not an automatic barrier to employment with _______________ ( HCO) . _____________ ( HCO) evaluates information about prior convictions relative to the date of the conviction, the applicant’s post-conviction experiences, and the specific job with ______________ ( HCO) under consideration. 4. Fraud Abuse and Control Information System (FACIS). As part of our Medicare compliance program. _______________ ( HCO) reviews FACIS on all job applicants before extending an offer of employment. We also review FACIS annually on all current staff. FACIS includes information on individuals and organizations that have been excluded from federal health care programs, such as Medicare. Because the information obtained through FACIS is public information, we do not require written authorization to perform this search. Nevertheless, we inform all job applicants and current staff that we will be reviewing this information. I certify that I have read the above. 6 Signature of Applicant _______________________________________ Date __________________ Print Name: ______________________________________ ______ A Summary of Your Rights Under the Fair Credit Reporting Act Para informacion en espanol, visite www.ftc.gov/credit o escribe a Ia FTC Consumer Response Cenier. Room 130-A 600 Pennsylvania Ave. N. W, Washington, D.C. 20580. The Federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of infocmation in the files of consumer reporting agencies. There are many types of consumer reporting agencies. including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.ftc.ov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580. You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment — or to take another adverse action against you — must tell you, and must give you the name, address, and phone number of the agency that provided the information. You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if: i. a person has taken adverse action against you because of information in your credit report; ii. you are the victim of identify theft and place a fraud alert in your file; iii. your file contains inaccurate information as a result of fraud; iv. you are on public assistance; v. you are unemployed but expect to apply for employment within 60 days. In addition, all consumers will be entitled to one free disclosure every 12 months upon request fr&m each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.ftc.gov/credit for additional information. You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender. 7 You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.ftc.gov/credit for an explanation of dispute procedures. Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate. Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seen years old, or bankruptcies that are more than 10 years old. Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access. You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.ftc.gov/credit. You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at I -888-5-OPTOUT (1 -888-567-8688). You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court. Identity theft victims and active duty military personnel have additional rights. For more information, visit www.ftc.gov/credit. I certify that I have read the above. Signature of Applicant _______________________________________ Date __________________ Print Name: _______________________________________ _______ 8 Consumer Report -- Investigative Consumer Report Disclosure and Release Authorization I understand that in connection with my application for employment, ______________ (HCO) will obtain an Investigative Consumer Report on me for employment purposes. I hereby give consent for an investigative consumer report to be done on me, and I hereby authorize, without reservation, any person, law enforcement agency, state agency, former employer, corporation, partnership, limited liability company, credit agency, educational institution, city, state, federal court, military institution, employer or insurance company contacted by _______________ (HCO) or ____________________ ________________________________________ (name of consumer reporting agency) , to furnish any and all information required. I understand that the investigation will include information from law enforcement agencies, state agencies and public records information, such as credit, social security, criminal, motor vehicle and workers' compensation in accordance with the American with Disabilities Act. This report will include information as to my character work habits, performance and experience, along with the reasons for termination of past employment from previous employers. I do hereby release the aforesaid parties from any liability and responsibility for collecting the above information at any time. According to the Fair Credit Reporting Act (Law 91-508) SS 606: A person may not procure or cause to be prepared an investigative consumer report on any consumer unless it is clearly and accurately disclosed to the consumers that an investigative consumer report including information as to his character, general reputation, personal characteristics and mode of living and employment history, whichever are applicable, may be made. I also understand that if I am denied employment because of the consumer investigation, it is my right to have the name of the agency or agencies disclosed to me within the time allowed. This authorization, in original or copy form, shall be valid for this and any further reports or updates that may be requested. Witness my signature this __________________________________ (date) . Signature of Applicant _______________________________________ Print Name: _______________________________________ _______ 9