Employment Experience
Please list the names of your present or previous employers in chronological order with present or most recent employer listed first. Be sure to account for all periods of time. If self-employed, give firm name and supply business references. Add additional page if necessary.
Have you ever been involuntarily terminated or asked to resign from any job?.
Yes
NO
If yes, please explain
Please explain any gaps in your employment history:
Please list any other job related skills, additional languages, or other job related qualifications that you believe should be considered in evaluating your qualifications for employment.
How did you hear about us?
Indeed
Google
Employee at facility
Other
General Information
1. Have you ever used another name? Yes
No
2. Is any additional information relative to name changes, use of an assumed name, or nickname necessary to enable a check on your work and educational record? Yes
No
a. If yes to either of the above, please explain:
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3. Have you ever been convicted of any crimes? Yes
No
a. If yes , please explain:
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4. Have you ever been put on a United States Sanction list? Yes
No
5. Have you ever been excluded from participation in Medicare, Medicaid or any government health program or are considered an “ineligible person”? Yes
No
8. Are you available to work? Full-time
Part-time
Shift Work
Temporary
9. Minimum salary required?
Per Hour $ Per Month $
10. If hired, would you have a reliable means of transportation to and from work?. Yes
No
11. Are you at least 18 years old?. Yes
No
a. Note: If under 18, hire is subject to verification that you are of minimum legal age.
12. If hired, can you present evidence of your identity and legal right to work in this country? Yes
No
I hereby authorize the Company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the prior employers and references I have listed to disclose to the Company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
In the event of my employment with the Company, I understand that I am required to comply with all rules and regulations of the Company.
If hired, I understand and agree that my employment with the Company is at-will, and that neither I, nor the Company is required to continue the employment relationship for any specific term. I further understand that the Company or I may terminate the employment relationship at any time, with or without cause, and with or without notice. I understand that the at-will status of my employment cannot be amended, modified, or altered in any way by any oral modifications.
I understand that safety of employees is extremely important to the Company and that the Company is committed to ensuring a safe working environment. I understand that I, and every employee, have a responsibility to prevent accidents and injuries by observing all safety procedures and guidelines and following the directions of my site supervisor. I understand and agree to comply with federal, state, and local regulations related to on-the-job safety and health.
I hereby certify that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
I understand that if I am selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration laws require me to complete an I-9 Form in this regard.
I understand that if any term, provision, or portion of this Agreement is declared void or unenforceable, it shall be severed, and the remainder of this Agreement shall be enforceable.
MY SIGNATURE BELOW ATTESTS TO THE FACT THAT I HAVE READ, UNDERSTAND, AND AGREE TO ALL OF THE ABOVE TERMS.
Printed Name
CRIMINAL BACKGROUND CHECK RELEASE
Notification
The position for which I am being considered requires me to consent to a criminal background check as condition of employment. This check includes the following: Criminal history reference searches for felony and misdemeanor convictions at the county and federal levels of every jurisdiction where I currently reside or where I have resided during the past 7 years; and sex offender registry searches at the county and federal levels in every jurisdiction where I currently reside or where I have resided.
Authorization
I hereby authorize Innovative Health Care to conduct the criminal background check described above. In connection with this, I also authorize the use of law enforcement agencies and/or private background check organizations to assist Innovative Health Care in collecting this information. Applicant Safe has been secured as a third-party vendor to assist Innovative Health Care in collecting and verifying information.
I also am aware that records of arrests on pending charges and/or convictions are not an absolute bar to employment. Such information will be used to determine whether the results of the background check reasonably bear on my trustworthiness of my ability to perform the duties of my position in a manner which is safe for Innovative Health Care employees and residents.
Full legal name
Other names you have used in past 7 years
Driver’s License Number
Current Address
To the best of my knowledge, the information provided in this Notice and Authorization and any attachments thereto is true and complete. I understand that any falsification of omission of information may disqualify me for this position and/or may serve as grounds for the severance of my employment with Innovative Healthcare Group. By signing below I hereby provide my authorization to Innovative Health Care to conduct a criminal background check and I acknowledge that I have addition to those rights, I understand that I have a right to appeal an adverse employment decision made by Innovative Health Care based on my background check information within three business days of receipt of such notice and that a determination on my appeal will be made in seven working days from Innovative Health Care's receipt of such appeal.
Printed Name
CONSENT FOR RANDOM OR REASONABLE SUSPICION DRUG TEST AND RELEASE COVENANT NOT TO SUE
INDEMNITY AGREEMENT
I hereby CONSENT to allow Innovative Healthcare Group to take a specimen of my urine and submit in the event of a random drug test screen. I FURTHER CONSENT to allow the laboratory testing service to make the results of such screen available to the prospective or current employer, Innovative Healthcare Group.
In consideration for such services being rendered on my behalf, I hereby RELEASE the laboratory testing service, its officers, agents, and employers, from any and all claims which I might otherwise have due to such results being made so available. I hereby CONSENT NOT TO FILE ANY ACTION at law or in equity against Innovative Healthcare Group, laboratory testing service, their respective officers, agents, or employers in connection with the results of such screen being made so available, and I hereby agree to INDEMNIFY and SAVE HARMLESS Innovative Healthcare Group, the laboratory testing service, their respective officers, agents, and employers from all damages, expenses, reasonable attorney's fees, and costs of court which they or any of them may suffer or incur, jointly or severally, due to the results of such screen being made so available.
Printed Name
