Online Application for Employment
Name (*)
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last. . first. . middle
Date (*)
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Present Address (*)
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Address: (*)
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Phone: (*)
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Alternate Number:
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Are you eligible to work in the United States? (*)
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Have you ever worked for a hospital, nursing home, homecare, or any medical related field? (*)
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Have you ever been convicted of a crime(excluding traffic violations)? (*)
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If yes, please explain
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Names of relatives employed here:
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Names of friends employed here:
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Have you ever applied for work here before? (*)
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If yes, when?
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Check all positions you are applying for:
Nursing:
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Dietary
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Therapy:
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Other Position:
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Wages Expected? (*)
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Amount (*)
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Do you want Full Time or Part Time?
(*)
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If Full Time, which shift would you prefer?
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If Part Time, how many hours per week?
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Which days per week are you available?
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After what date are you available to work?
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Have you read the job description(s) for the job(s) for which you are applying?
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Are you able to perform all the tasks described?
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If no, which tasks are you unable to perform?
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If licensed or certified by any State in the health care field, please give number and State of License
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Account for all periods of employment and unemployment:(Most current employment first)
May we contact the employers listed above?
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If not, Indicate which ones you do not wish us to contact
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MILITARY SERVICE
I hereby verify that if I become employed, I understand that as a continuing condition of my employment, I will:
1. Maintain positive and harmonious relationships with patients, visitors and staff
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2. Appear for duty as scheduled or at least to secure a replacement in the event of unforeseen circumstances
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3. Be a team member, rendering help to fellow staff in other departments as needed
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I certify that the information contained in this application is correct and understand that falsification of this document in any detail or omission of information is grounds for disqualification from further consideration or for dismissal from employment, I agree to conform to the rules and regulations of this establishment, and understand that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, At the option of either the company or myself, I also agree to submit to a physical examination if any employment offer is extended and to cooperate fully with other examinations or investigations that may be requested by the employer from time to time as an ongoing condition of employment.
Therefore, you are authorized by my signature below to make such Initial investigations you deem necessary as to personal character, reputation, work history, credit record, convictions or other such lawful inquiries prior to or during employment.
I understand that this application will be active for 60 days If not employed; thereafter, I will have to reapply.
I attest that to the best of my knowledge that I am not an "Ineligible Person" who is currently excluded, debarred or otherwise ineligible to participate in the federal health care programs or in federal procurement or non-procurement programs. To the best of my knowledge, I am not listed on the General Services Administration's List of Parties Excluded from Federal Programs nor on the HHS/OIG List of Excluded Individuals/Entities. Furthermore, I have never been convicted of any felony criminal offense.
I, of my own free will, without promises of immunity, threats or coercion, agree to allow Sterling Testing Systems, Inc. to conduct a background investigation and credit report.
I hereby agree that the results of such investigation and its conclusions that may be used by Sterling
Testing Systems, Inc., its officers, agents, and employees both orally and in writing, in order to process my employment application.
I full well understand that the results of this background investigation and the conclusions drawn
therefore from Sterling Testing Systems, Inc., its officers and employees may prove unfavorable to me. I do nonetheless hold Sterling Testing Systems, Inc., its officers, agents and employees and the organization shown on line #1 above free and harmless from any claim I might otherwise have against them for any damages or liability to me resulting from this background investigation.
In order to verify my identity for purposes of the background investigation, I am voluntarily releasing my date of birth for my own benefit and fully understand that age is not a consideration of employment.
I have received a stand alone, consumer notification that a consumer report may be requested and used for the purpose of evaluating me for employment, promotion, and retention as an employee.
NHC will not knowingly hire anyone who has been convicted of, plead guilty or' plead nolo contendere to any felony. Furthermore, NHC will not knowingly hire any applicant who has been convicted of, plead guilty plead nolo contendere to.a misdemeanor that would conflict With NHC's mission of providing quality care which includes but is not limited to: abuse or neglect of the elderly, abuse or neglect of a minor, abuse or neglect of an incapacitated person, or domestic yiolence against a protected person (i. e. the elderly, children and the mentally ill.
Applicants hired into financial positions shall not have been convicted of, plead guilty to or plead nolo contendere to crimes involving financial matters.
1 understand that any falsification of information on this form will be grounds for termination of my employment from NHC. I understand that NHC will use information on this form to determine if I am an
"Ineligible Person" by comparing Information on this form to the General Services Administration's List of Parties Excluded from Federal Programs and to the HHS/OIG List of Excluded Individuals Entities.
Further, I understand that a criminal background check of public records will be made to determine if I have ever been convicted, plead guilty to or plead nolo contendere to any felony or misdemeanor offense.
Signature
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Date
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