I certify that, to the best of my knowledge, the answers given are accurate and complete, and that any intentional misrepresentation may result in my application being denied.

I authorize educational institutions, associations, registration, and licensing boards, and others to furnish whatever detail is available concerning my qualifications. I authorize investigations of all statements made in this application and understand that false information of documentation, or a failure to disclose relevant information may be grounds for rejection of my application, disciplinary action, or dismissal if I am employed, and (or) criminal action. I further understand that dismissal shall be mandatory if fraudulent disclosures are given to meet any position. 

I consent to the investigation of all statements contained within this application, as necessary. In addition, I authorize former employers, references, and any other individuals/organizations to provide information to Ayuda Healthcare Staffing, and I hereby release and acquit all of the aforementioned parties, as well as Ayuda Healthcare Staffing from any liability of any kind or nature related to the investigation and verification of the information provided. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary.

I consent to a physical examination, if requested, and am aware that failure to satisfy the position's medical and/or health requirements could prevent my employment with the Agency. I am also aware that, for certain positions, employment may be contingent upon passing a drug test and a background check.

 

I also understand that, if hired, I may be required to provide evidence that I am a U.S. citizen or am authorized to work in the United States.

 

EEO Statement

We provide equal employment opportunities. All applicants shall be considered for employment without regard to their race, color, creed, religion, national origin, ancestry, citizenship status, age, physical or mental disability, sex or gender (including pregnancy), gender identity or expression (including transgender status), sexual orientation, veteran status, genetic information, or any other characteristic protected by applicable federal, state, or local laws.

We will make every effort to accommodate the known physical or mental limitations of a qualified applicant with a disability, unless doing so would impose an undue hardship on our business operations. Please contact us if you believe you need assistance to complete this form or to participate in an interview.

 

Other State Specific Notices and Disclaimers
PLEASE READ CAREFULLY

Maryland Applicants: Under Maryland law, an employer may not require or demand, as a condition of employment, prospective employment or continued employment, that an individual submit to or take a lie detector or similar test. An employer who violates this law is guilty of a misdemeanor and subject to a fine not exceeding $100.

Massachusetts Applicants: Note that it is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Michigan Applicants: Persons with disabilities needing accommodations for employment must notify the Company in writing of the need for an accommodation within 182 days after the date the person with a disability knew or reasonably should have known that an accommodation was needed.

Rhode Island Applicants: The Company is subject to Chapters 29-38 of Title 28 of the General Laws of Rhode Island and is therefore covered by the state’s workers’ compensation law.

Arizona Applicants: To the extent required by applicable law, the Company maintains a smoke-free workplace.

PUBLIC RECORDS DISCLOSURE

I acknowledge that in connection with my application for employment or subsequent employment, The Company may collect, assemble, evaluate, compile, report, transmit, transfer or communicate information on my character, general reputation, personal characteristics or mode of living which are matters of public record without using a third party investigative consumer reporting agency. Matters of public record are defined as records documenting an arrest, indictment, conviction, civil judicial action, tax lien, or outstanding judgment.

I understand that such public record information generally must be disclosed to me within seven days of the date the information is received, regardless of whether it is received orally or in writing. I understand that I may waive my right to receive such information.

Applicant Privacy Notice

Applicant Personal Information. The chart below describes the categories of Applicant Personal Information that may be collected in connection with the application and the purposes for which such information may be used.

Categories of Personal Information Collected

Identifiers and Contact information. This category includes names, addresses, telephone numbers, mobile numbers, email addresses, dates of birth, Social Security numbers, driver’s license or state identification numbers, and other similar contact information and identifiers.

Protected classification information. This category includes characteristics of protected classifications under California or federal law.

Internet or other electronic network activity information. This category includes without limitation:

all activity on the Company’s information systems, such as internet browsing history, search history, and email communications
all activity on communications systems including phone calls, call logs, voice mails, text messages, chat logs, and app use
 
 Geolocation data. This category includes GPS location data from company-issued mobile devices and company-owned vehicles.

Audio, electronic, visual, thermal, olfactory, or similar information. This category includes, for example, information collected from camera, thermometers, and similar devices.

Professional and employment-related information. This category includes without limitation:

data submitted with employment applications including employment history, recommendations, etc.
background check and criminal history
work authorization
fitness for duty data and reports
Education information. This category includes education history.

Limited medical information. This category includes without limitation:

 symptoms and other indicators of exposure to the coronavirus, COVID-19
fitness for duty data and reports
leave of absence information including family obligations, physical and mental health data concerning employee and his or her family members
travel information and information regarding close contacts
 
Purposes Personal Information is Used.

Collect and process employment applications, including confirming eligibility and qualifications for employment, background and related checks, as necessary.
Evaluate an individual’s appropriateness for a particular position at the Company, or promotion to a new position.
Communicate with you about your application.
Maintaining personnel records and record retention requirements.
Complying with applicable state and federal labor, employment, equal employment opportunity, and related laws.
Preventing unauthorized access to or use of the Company’s property, including the Company’s information systems, electronic devices, network, and data.
Investigating complaints, grievances, and suspected violations of Company policy.
Protect the legal rights, privacy, safety or property of Company or its employees, agents, contractors, customers or the public.
Protect against fraud or other illegal activity or for risk management purposes.
Enforce the Site’s terms of use
Carry out a license, sale or transfer of all or a portion of the business or assets (including in connection with any bankruptcy or similar proceedings), or manage or arrange for acquisitions, mergers and re-organizations.
Design, implement, and promote the Company’s diversity and inclusion programs
Improve safety of our facilities for employees, customers and the public with regard to use of Company property and equipment
 
To carry out the purposes outlined above, the Company may share information with third parties, such as background check vendors, third-party human resources and information technology vendors, outside legal counsel, and state or federal governmental agencies. The Company may add to the categories of PI it collects and the purposes it uses PI. In that case, the Company will inform you.

If you have questions about this notice, you may call (888) 788-2983.

Changes to Statement. We reserve the right to amend this Notice at any time without advance notice.

Submittal Disclaimer

I certify that the information contained in this application is correct and complete to the best of my knowledge. I understand that any falsification or omission of information may disqualify me from further consideration for employment or, if hired, may result in termination. I authorize any person, organization or company listed on this application to furnish you any and all information concerning my previous employment, education and qualifications for employment. Unless I noted otherwise, I authorize the Company to contact all my employment references and personal references, as well as the education institutions I have attended. In consideration for my employment, I agree to abide by the rules and regulations of the company, which rules may be changed, withdrawn, added or interpreted at any time, at the company’s sole option and without prior notice to me.

I understand that any hiring decision is contingent upon my successful completion of all of the Company’s lawful pre-employment/post-offer checks, which may include a background check. If I am made a conditional offer of employment, I agree to execute any consent forms necessary for the Company to conduct its lawful pre-employment/post-offer checks. Such checks will not be conducted until allowed under applicable federal, state and local law. I understand if I have a criminal background, it will not automatically disqualify me from employment unless otherwise required by law. I agree to execute any consent forms necessary for the Company to conduct its lawful pre-employment checks.

I understand the Company may obtain, without using the services of a third-party investigative consumer reporting agency, public records pertaining to my character, general reputation, personal characteristics or mode of living during its evaluation of my application for employment and, if employed, during my employment. I waive my right to receive copies of public records obtained by the Company.

I understand that nothing contained in the application or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Company’s designated representative. In addition, I understand that the Company and all plan administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits or other terms and conditions of employment.

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

I also understand that the Company is a drug and alcohol-free workplace and has a drug and alcohol testing program consistent with applicable federal, state, and local law. I understand that after a conditional offer of employment, I must submit to and pass a pre-employment drug test as a condition of employment.

I understand that the Company recommends that I do not resign from my current job until satisfactory post-offer, pre-employment background checks and a drug screen are received and processed.