Please Read and Initial Each of the Following Statements. This Application is Invalid Without Your Initials and Signature Below.
ACCURACY OF INFORMATION PROVIDED AND SIGNIFICANCE OF THIS APPLICATION: I certify that all information on this application is correct and true and I understand that any misrepresentation or willful omission of material facts will be sufficient reason for the rejection of my application for employment, or if employed, my immediate discharge. I understand that this application is not a contract, offer, or promise of employment and that, if hired, I will be able to resign at any time for any reason and that the employer can likewise terminate my employment at any time, with or without cause. I also understand that while personnel policies, programs, and procedures may of necessity change from time to time, my status as an at will employee, if I am hired, is not subject to change absent a written agreement signed by the president of the employing organization, or designated authorized representative. I have read, understand, and agree to the above statements. (please initial here)
statements. (please initial here)
PRE-HIRE DRUG TESTING AND POST-OFFER PRE-EMPLOYMENT MEDICAL EXAMINATION: I understand that this employer requires all job applicants to successfully pass a substance abuse test as a term and condition of an offer of employment. I further understand that I will be required to sign a test consent form and that my failure or refusal to do so will result in denial of employment. If the results of such tests indicate the presence of any illegal, controlled, or unauthorized drugs in my blood or urine, I will not be eligible for employment. I further understand that any job offer made is conditioned on the satisfactory outcome of a medical examination required for all employees, which would be conducted at the employer's expense before employment would begin. I have read, understand and agree to the above statements. (please initial here)
and agree to the above statements. (please initial here)
DRUG FREE WORKPLACE COMPLIANCE: I understand that the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance on company premises or while conducting company business off company premises is absolutely prohibited. If employed by this employer, I agree as a condition of employment to abide by the terms of the Drug-Free Workplace Act of 1988 and any policies relating to this Act and to report any conviction under a criminal drug statue for violations occurring on or off company premises while conducting company business within five (5) days after such conviction. I further understand and agree that if I am employed, I may be required to submit to alcohol / drug testing under circumstances giving rise to reasonable suspicion of alcohol / drug use during my employment and that my refusal to submit to such testing is grounds for immediate termination of my employment. I have read, understand and agree to the above statements. (please initial here)
and agree to the above statements. (please initial here)
AUTHORIZATION TO INVESTIGATE BACKGROUND: The employer, in considering my application for employment, may verify the information set forth on this application and obtain additional information relating to my background. I authorize all persons, schools, companies, law enforcement agencies, and former employers to supply this employer any information concerning my background and consent to the release of such information. I authorize this employer to investigate all information and release this employer and all persons, schools, companies, corporations, law enforcement agencies, and former employers from all liability and responsibility for furnishing any information concerning my background or confirming the information in this application. I further understand that any job offer made is conditioned on the satisfactory outcome of a background check required for all employees, which would be conducted at the employer's expense before employment would begin. I have read, understand and agree to the statements above. (please initial here)
statements above. (please initial here)
REFERENCE RELEASE: I authorize Our Hospice of South Central Indiana and any parties they engage to make confidential inquiries and investigations covering my background (to include present and previous employment, present and previous education, police department records, court records, and personal references) as a condition for employment. I hereby release Our Hospice of South Central Indiana, Inc., its agents, employees, and designees (including those contracted by these parties) from and for any and all liability arising from such inquiries and investigations.
Signature:
(type name in signature block)
EXPIRATION DATE OF EMPLOYMENT APPLICATION: I understand that this application is good for six (6) months from today's date. If I still desire a position with this employer after this expires, it will be my responsibility to complete a new application and submit it for consideration. Otherwise, this employer will not consider me for employment after this application expires. I understand that completion of this application for employment form does not guarantee that I will be employed by this employer. I have read, understand, and agree to
the statement above. (please initial here)
Date of Application:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature:
(type name in signature block)
HR-13 (01.01.13)
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California Applicants:
As a California applicant, I understand that I have the right under Section 1786.22 of the California Civil Code to contact the Agency during reasonable hours (9:00 a.m. to 5:00 p.m. (PTZ) Monday through Friday) to obtain all information in Agency's file for my review. I may obtain such information as follows: 1) In person at the Agency's offices, which address is listed above. I can have someone accompany me to the Agency's offices. Agency may require this third party to present reasonable identification. I may be required at the time of such visit to sign an authorization for the Agency to disclose to or discuss Agency's information with this third party; 2) By certified mail, if I have previously provided identification in a written request that my file be sent to me or to a third party identified by me; 3) By telephone, if I have previously provided proper identification in writing to Agency; and 4) Agency has trained personnel to explain any information in my file to me and if the file contains any information that is coded, such will be explained to me.
New York Applicants:
I understand that if I am applying for employment in New York, that I have the right to receive a copy of Article 23-A of the New York Correction Law ____________________ (initial if this applies).
Washington Applicants:
I understand that if the report is provided to an employer in the State of Washington, that I can contact the following office for more information regarding my rights under Washington state law in regard to these reports: State of Washington Attorney General, Consumer Protection Division, 800 5th Ave, Ste. 2000, Seattle, Washington 98104-3188, (206) 464-7744.
Please complete all of the fields below:
I understand that I have rights under the Fair Credit Reporting Act and I acknowledge receipt of the Summary of Rights.
Name
First Name
Middle Initial
Last Name
Social Security #:
Email:
*
example@example.com
Current Address:
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Rows
Drivers Lic. #:
State Issuing:
1
2
3
Applicant Signature (type name for signature)
Rev. 05.17.2016
www.wescreenusa.com
Previous Address:
Previous Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email form to KWhitehead@ourhospice.org
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone:
*
Format: (000) 000-0000.
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