RN :LPN Pre- Contract Forms

Have you ever been convicted of a Felony?
If so please explain*
Do you have 6 or more points on your driving record*
Please list the states you have lived in for the past seven years.*
STATEMENT OF AUTHORIZATION
Please read the information on this form carefully and completely.

I have applied for employment with Nattingham Home Care LLC and have provided information about my previous employment. I authorize Nattingham Home Care LLC to conduct a reference check with my present and/or previous employer(s

I understand that reference information may include, but not be limited to, verbal and written inquiries or information about my employment performance, professional demeanor, rehire potential, dates of employment, salary, and employment history. My signature below authorizes my former or current employers and references to release information regarding my employment record with their organizations and to provide any additional information that may be necessary for my application for employment with Nattingham Home Care LLC, whether the information is positive or negative. I knowingly and voluntarily release all former and current employers, references, and Nattingham Home Care LLC from any and all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications, and my suitability for employment with Nattingham Home Care LLC.

I further authorize Nattingham Home Care LLC to obtain feedback and references from my supervisors over the course of my employment with Nattingham Home Care LLC. I understand that subsequent and continued employment with Nattingham Home Care LLC may be subject to this feedback. This form may be photocopied or reproduced as a facsimile, and these copies will be as effective as a release or consent as the original which I sign.
Employee Signature*

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Employee Name Printed*
Date*

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Date
EQUAL OPPORTUNITY EMPLOYER
It is the policy of Nattingham Home Care LLC, in accordance with all applicable laws, to recruit, hire, train, and promote persons in all job titles without regard to race, color, national origin, genetic information, religious beliefs, sex, gender identity, sexual orientation, age, marital status, pregnancy, disability, protected veteran status, or any other protected classifications, activities, or conditions as required by federal, state and local laws.

All employment decisions shall be consistent with the principle of equal employment opportunity, and only valid qualifications will be required.

By signing in the space provided below, you hereby acknowledge that you have been given a copy of the Nattingham Home Care LLC's Equal Opportunity Employer Statement and, that you have read the Statement and that you understand its contents.
Signature of Employee*

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Employees Name Printed*
Date*

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Date
I certify that the facts set forth in the above employment application are true and complete to the best of my knowledge. I understand that falsified statements on this application in any detail shall be considered sufficient cause for disqualification from further consideration for hire

False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment.

I also understand that due to the nature of the business, no amount of work can be guaranteed.

By signing in the space provided below, you hereby acknowledge that you have read the Statement above and that you understand its contents and agree to its contents.
Signature of Employee*

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Employees Name Printed*
Date*

MonthDayYear
Date
5 YEAR OHIO RESIDENCY- STATEMENT
Name*
Date of Birth*

MonthDayYear
Date
I certify that I am the person described above that I am a permanent resident of the state of Ohio, and that I have been residing in Ohio for at least 5(five) years prior to today's date.
Employee Signature*

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Date*

MonthDayYear
Date
EMPLOYEE'S AUTOMOBILE RELEASE OF LIABILITY
It is my understanding that my vehicle is a part of the duties in the care of clients assigned to me.

I also acknowledge that I have the primary and sole responsibility for my vehicle

I agree to hold Nattingham Home Care LLC and its agents harmless in the event that there is any type of accident in which there is any damage of any sort to my vehicle or to the property of others or injury to myself or any other persons, including vehicle occupants.

I agree to maintain insurance coverage and to provide Nattingham Home Care LLC with proof of coverage, including current dates and limits of liability.

I acknowledge that I have the primary and sole responsibility for my automobile in safe operating condition and to comply with all driving and traffic laws.

I have read and understand the information above.
Employee Signature*

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Date*

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REQUEST FOR COPY OF OHIO BACKGROUND CHECK:
REASON FINGERPRINTED ON LAST BACKGROUND CHECK
REASON FINGERPRINTED FOR THIS BACKGROUND CHECK
*The Ohio Revised Code must be listed in both spaces above NAME (must be the same name submitted with fingerprints):
NAME must be the same name submitted with fingerprints*
SSN*
DOB*
SEND BACKGROUND RESULT TO:
NAME
STREET
CITY
STATE
ZIP CODE
Return this letter with your payment of $8 (if required), payable to Treasurer, State of Ohio. I hereby certify that I have given the above mentioned person or agency permission to obtain a copy of any conviction record pertaining to me in the files of the Ohio Bureau of Criminal Investigation.
*REQUIRED: APPLICANTS SIGNATURE:
APPLICANTS SIGNATURE*

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DATE*

MonthDayYear
Date
APPLICANT'S PHONE NUMBER*
P.O. Box 365 I London, Ohio I 43140 www.OhioAttorneyGeneral.gov
Should be Empty:

STATEMENT OF AUTHORIZATION

EQUAL OPPORTUNITY EMPLOYER

5 YEAR OHIO RESIDENCY- STATEMENT

EMPLOYEE'S AUTOMOBILE RELEASE OF LIABILITY

REQUEST FOR COPY OF OHIO BACKGROUND CHECK:

SEND BACKGROUND RESULT TO:

*REQUIRED: APPLICANTS SIGNATURE: