Application for Employment

Transcription

1 Application for Employment NETCARE CORPORATION 199 South Central Avenue Columbus, OH (614) Applicants are considered for all positions in accordance with statutes and regulations concerning non-discrimination on the basis of race, ancestry, age, color, religion, sex, national origin, sexual orientation, non-disqualifying disability, veteran status, or other protected classification. Netcare is an equal opportunity employer, as well as a substance and tobacco free workplace. All offers of employment are contingent on satisfactory pre-employment drug screen, criminal background investigation and TB test results. A resume may not be used in lieu of completing this application. (Please Complete Each Field) Date of Application Position(s) Applied for Referral Source: Advertisement (list source) Friend Relative Present or former staff member (name) Other (list) Last First Middle Social Security Number Address Number Street City State Zip Code Home Telephone ( ) Cell Telephone (Optional) ( ) address: If applying for a direct service position, are you at least 21 years of age? If employed and you are under 18, can you furnish a work permit? Have you ever been employed by Netcare before? If yes, give date: Are you employed now? If yes, may we contact your current employer? Do you have relatives working for Netcare? If yes, who? Are you authorized to work in the United States under present immigration laws? (Proof of identity and employment eligibility will be required upon employment) Are you available to work (Check all that apply) FULL-TIME PART-TIME DAYS EVENINGS WEEKENDS When can you begin work? Rev. 8/22/ A

2 Previous Employment A resume may not be used in lieu of completing this section. Go back at least 5 years, further, if space allows. Please give accurate, complete full-time and parttime employment record. Start with present or most recent employer. If you ve had any gaps in employment, please explain. Note if you worked under a different name than that listed on the front of this application. 1. Company Telephone of Supervisor Start Finish 2. Company Telephone of Supervisor Start Finish 3. Company Telephone of Supervisor Start Finish 4. Company Telephone of Supervisor Start Finish

3 Education High School College/University Graduate/Professional* School and Location Years Completed Diploma/Degree* Describe Course of Study Describe Specialized Training or Skills Current License & License No s.* *Note: Official copies of transcripts, licenses, or certificates will be required if a conditional offer of employment is made. Have you served in the U.S. Armed Forces? Branch Number of Months in Service Background Information Instructions and important note about the following questions: Circle the proper response for each question below. Answering yes on any of the questions below will not automatically disqualify you from consideration for employment. We will consider the date and facts of each event you list. When answering these questions, you may omit: 1) any conviction set aside under the Federal Youth Corrections Act or State Law; 2) any conviction whose record was expunged under Federal or State law; 3) any criminal arrest, investigation, or hearing that did not lead or has not yet led to a conviction. 1. Have you ever been convicted of or forfeited collateral for a criminal offense (misdemeanor/felony)? 2. Are there charges pending against you by any professional ethics boards, federal or state regulatory agencies, or professional regulatory bodies (example: The American Medical Association) for violations of the law, violations of ethics codes, professional misconduct, incompetence or negligence? 3. Has any civil, administrative, or private regulatory professional liability claim been made against you? 4. Have you ever had any insurance company decline, cancel or refuse to renew or accept on special terms any professional liability insurance? * IMPORTANT* If you answered YES to the above questions, you must provide the information below; use additional pages if necessary. Failure to provide this information may disqualify you from further consideration for employment. Date: Charge: Place (City and State): Court and Action Taken:

4 Applicant s Statement I certify that answers given herein are true and complete. I understand that any incorrect information or omission is reason for not being hired or dismissal if I am employed, regardless of when the correct information is discovered. I hereby authorize any person or entities to provide Netcare Corporation with reports containing any and all information about my previous employment, education, criminal background and any other pertinent information they may have, personal or otherwise, and I hereby release all parties furnishing any such information from all liability for any damage that may result to me from the release of such information. Furthermore, if I am hired, I hereby authorize Netcare Corporation to obtain reports about me at any time during my employment. I understand that no position within Netcare is guaranteed for any length of time, and either Netcare or I can terminate the relationship at will at any time, for any reason. I understand that no employee of Netcare has any authority to alter my at-will employment status or Netcare's policies (with which I agree to comply in consideration of my employment if I am employed), except the Chairperson of the Board of Directors who may only do so in writing. Signature of Applicant (Type your name and date if submitted electronically) Complete the remainder of this application only after you have been hired: 1. Birthdate: 2. Age: 3. Sex: 4. SS#: 5. Race: 6. and phone number of persons to contact in case of emergency: For Human Resources Use Only Employee Classification Date to Begin Employment Full-time Part-time Contingent Department Other Job Title Hourly Rate Annual Salary Date Location and Shift Vacation Accrual Recommendation to Hire: Director of Human Resources (Date) Approval to Hire: President, CEO (Date)

5 NETCARE CORPORATION RELEASE AUTHORIZATION I In connection with my application for employment, or during the course of my employment, I understand that a consumer report may be requested that will include information as to my character, work habits, performance and experience. I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my: driving record, court record, criminal arrests and/or conviction record, worker compensation claims, work experience, education, credentials, credit, reasons for terminations and references. II. According to the Fair Credit Reporting Act, I am entitled to know if employment is going to be denied, or if my employment will be adversely effected, because of information obtained by Netcare from a consumer reporting agency. If so, I will be notified and given a summary of my rights, a copy of the report and the name and address of the agency which provided the information. III. I hereby authorize, without reservation, any law enforcement agency, credit reporting agency, institution, information service bureau, school, Netcare Corporation, or reference contacted by its agent, to furnish the information described in Section I. The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. I hereby release Netcare Corporation and agents and all person, agencies, and entities providing information or reports about me from any and all liability arising out of the request for or release of any of the above mentioned information or reports. (Last, First, Middle) Alias Home Address City State Zip Code Social Security Number Applicant Signature Today's Date 1. In accordance with the provisions of Section 604 and Section 607 of the Fair Credit Reporting Act, Public Law No , I hereby certify that the information requested above will be used for a "permissible purpose" as defined in the Act, and that the information received will be used for no other purpose. 2. I further certify that if the applicant named above is denied employment based upon the information received, I will identify the source of the report in accordance with Section 615(a) of the Fair Credit Reporting Act. Signature of Requester Today's Date

6 Professional References Please fill in the names and addresses of three individuals, other than relatives, whom we may contact for a professional recommendation. I hereby authorize Address City State Zip Code Daytime Telephone to disclose any knowledge of information which he/she thereby acquired relevant to my employment. I hereby consent that they may disclose such information to the Human Resources Department of Netcare. I hereby release all parties furnishing any such information from all liability for any damage that may result to me from the release of such information. Print Applicant's Signature Date I hereby authorize Address City State Zip Code Daytime Telephone to disclose any knowledge of information which he/she thereby acquired relevant to my employment. I hereby consent that they may disclose such information to the Human Resources Department of Netcare. I hereby release all parties furnishing any such information from all liability for any damage that may result to me from the release of such information. Print Applicant's Signature Date I hereby authorize Address City State Zip Code Daytime Telephone to disclose any knowledge of information which he/she thereby acquired relevant to my employment. I hereby consent that they may disclose such information to the Human Resources Department of Netcare. I hereby release all parties furnishing any such information from all liability for any damage that may result to me from the release of such information. Print Applicant's Signature Date

7 Completion of this page is voluntary. Applicant Data Record Applicants are considered for all positions, and employees are treated during employment without regard to race, color, religion, sex, national origin, ancestry, or disability. As an employer, we comply with government regulations and affirmative action responsibilities. Solely to help us comply with government record keeping, reporting, and other legal requirements, please fill out the Applicant Data Record. We appreciate your cooperation. This data is for annual government reporting and will be kept in a Confidential File separate from the Application for Employment. (Please Print) Date Position(s) Applied For: Referral Source: Advertisement Friend Relative Walk-in Employment Agency Other (list source) Phone Last First Middle Area Code Number Street City State Zip Code Affirmative Action Survey Government agencies require periodic reports on the sex, ethnicity, handicapped and veteran status of applicants. This data is for analysis and affirmative action only. Check One Male Female Check one of the following White Black Hispanic American Indian/Alaskan Native Asian/Pacific Islander Check if either of the following is applicable: Veteran Disabled Veteran