From: Date To: Date Final pay rate:
CAJ SERVICES RELEASE OF INFORMATION (APPLICANT WILL SIGN & DATE)
I, , authorize CAJ SERVICES to make inquiries of my former(Print your name)employers regarding my past employment record, including dates of employment, salary, performance evaluation, etc., for the purposes of assessing my qualifications for employment.
WAIVERS AND DISCLOSURES
Please read each section carefully and sign where indicated.
It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits by this organization. I understand and agree that, if hired; my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either my employer or myself. I also understand that this written statement supersedes any and all oral representations made by agents or representatives of this organization.
CERTIFICATION OF TRUTH AND ACCURACY
I certify that the information in this application is true, complete and correct. I understand that false answers, statements, or significant omissions made by me on this form shall be sufficient cause for denial of employment or discharge.
NOTIFICATION AND AUTHORIZATION TO REQUIRE A TUBERCULOSIS SCREENING
I hereby certify that, if hired, I will disclose any limitations I have that may impact my ability to do the essential functions of the job. I further understand as a Health care employee I will be required to undergo a two-step Tuberculin skin testing by a PPD test or chest x-ray.
NOTIFICATION AND AUTHORIZATION TO CONDUCT BACKGROUND INVESTIGATION
I understand that I may be subject to a background check, CORI Check, and hereby authorize Department of Criminal Justice Information System (DCJIS), to investigate my background to determine any and all information of concern as to my record, whether same is of record or not, and I release employers and persons named in my application from all liability for any damages on account of his/her furnishing said information.
Additionally, you are hereby authorized to make any investigation of my personal history, educational background, military record, motor vehicle records and criminal records through an investigative or credit agency or bureau of your choice. I authorize the release of this information by the appropriate agencies to the investigating service. This authorization, in original or copy form, shall be valid for this and for any future reports and updates that may be required.
I understand that passing the background check is a condition of employment. A negative background check can be grounds for dismissal, even if an offer has been made to me and I have been hired.
Non-Discrimination Policy: CAJ Services is committed to the principle of equal opportunity in education and employment. The University does not discriminate on the basis of sex, race, color, creed, national origin, age, religion, sexual orientation, gender identity, gender expression, veteran status, or disability in admission to, access to, treatment in, or employment in its programs and activities.
The following person has been designated to handle inquiries regarding CAJ Services nondiscrimination policies:
Affirmative Action Survey
Government agencies require periodic reports on the sex, ethnicity, disability, and veteran status of applicants. Submission of information about a disability is voluntary. This data is for analysis and affirmative action only.
Special Employment Notice to disabled veterans, Vietnam Era veterans, and individuals with a physical or mental disability.Government contractors are subject to Section 402 of the Vietnam Era Veterans Readjustment Act of 1974 which requires that they take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended, which requires government contractors to take affirmative action to employ and advance in employment qualified disabled individuals.If you are a disabled veteran, or have a physical or mental disability, you are invited to volunteer this information. The purpose is to provide information regarding proper placement and appropriate accommodation to enable you to perform the job in a proper and safe manner. This information will be treated as confidential. Failure to