Odd Fellow & Rebekah Rehabilitation & HCC, Inc. 104 Old Niagara Road Lockport NY Phone:

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1 Odd Fellow & Rebekah Rehabilitation & HCC, Inc. 104 Old Niagara Road Lockport NY Phone: APPLICATION FOR EMPLOYMENT We consider applications for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status. We are an Equal Opportunity Employer. (Please Print) Notice to Prospective Employees As part of the application process, you will be required to undergo a criminal history record check (CHRC) by completing a ten point fingerprint card that is submitted to the Division of Federal Bureau of Investigation (FBI), for any criminal history records. You will have the opportunity to obtain, review & explain the information contained in the CHRC; and may withdraw your application for employment at any time, without prejudice, prior to the operator s decision on employment, and that upon such withdrawal, any fingerprints and criminal history record concerning the individual received by the operator shall be destroyed. Position Applied For: Date of Application: How did you learn about us? Advertisement Relative Friend Other Last Name: First Name: Middle Initial: : City: State: Zip Code: Phone # : Cell #: Social Security # (voluntary): - - Please complete and circle correct responses where appropriate Best Time To contact you is: AM/PM If you are under 18 years of age, can you provide required proof of your eligibility to work? YES / NO Have you ever filed an application with us before? YES / NO If Yes, give Approximate Date: Have you ever been employed with us before? YES / NO If Yes, give Approximate Date: Do you have any friends or relatives working here? YES / NO If Yes, Who? Are you currently employed? YES / NO May we contact your present employer? YES / NO Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? YES / NO Proof of citizenship or immigration status will be required upon employment Date Available for Work / / What is your desired salary range? Are you available to work: Full Time (Please indicate shift) Part Time (Please indicate shift) # Hours per week: Modified 1/24/13

2 Education Name & Course of Number of Years Diploma of School Study Completed Degree Elementary School High School Undergraduate/Graduate College Other (Specify) OTHER QUALIFICATIONS: Summarize special job-related skills & qualifications acquired from other experiences. Personal References All references must include COMPLETE addresses including zip codes or your application cannot be processed. A Telephone Book is available for our use if necessary. 1. Name 2. Name 3. Name

3 Employment Experience Start with your PRESENT employer or Last Job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin disabilities or other protected status. 1. Employer Dates Employed Worked Performed From To Job Title Reason for Leaving Supervisor Hourly Rate/Salary Starting Final 2. Employer Dates Employed Worked Performed From To Job Title Reason for Leaving Supervisor Hourly Rate/Salary Starting Final 3. Employer Dates Employed Worked Performed From To Job Title Reason for Leaving Supervisor Hourly Rate/Salary Starting Final 4. Employer Dates Employed Worked Performed From To Job Title Reason for Leaving Supervisor Hourly Rate/Salary Starting Final If you need additional space, please continue on a separate sheet of paper.

4 APPLICANTS: Circle every one of the following where you were previously employed. If you worked at a facility that is not listed below, please print the name of that facility at the bottom of the list. Absolut of Gasport Fairchild Manor Nursing Home Newfane Rehab. & Health Care Center Applegate Manor Garden Gate Health Care Facility Niagara Lutheran Home & Rehab. Bassett Manor Grace Manor Nursing Home Niagara Rehab. & Nursing Center Beechwood Residence & Nursing Home Greenfield Health & Rehab. Northgate Health Care Facility Briarwood Harris Hill Nursing Facility Odd Fellow & Rebekah Rehab. HCC Briody Health Care Facility Heritage Centers Opportunities Unlimited of Niagara Brothers of Mercy Nursing & Rehab. Heritage Manor Orchard Manor, Inc. Canterbury Woods Hospice Nursing Home Services Our Lady of Peace Catholic Charities of Buffalo Kenmore Mercy Hospital McAuley Oxford Village Crestwood Health Care Center Manor Oak Skilled Nursing Facility Presbyterian Homes Deaconess Center Long Term Care McGuire Group Rehabilitation Centers Schofield Residence DeGraff Memorial Skilled Nursing Medina Memorial Health Care Sheridan Manor Nursing Home ElderWood Health Care/Senior Care Millard Fillmore Hospitals Weinberg Campus Episcopal Church Homes & Affiliates Mount View Health Facility Williamsville View Manor Erie County Home Nazareth Nursing Home Williamsville Suburban Health & Rehab. Applicant s Statement I certify that answers given herein are true and complete. I authorize investigation of all statements contained in this application for employment. This application for employment shall be considered active for a period of time not to exceed 45 days. I understand that acceptance of an offer of employment does not create a contractual obligation upon the Employer to continue to employ me in the future. In the event of employment, I understand that false or misleading information given on my application or interview may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. Signature of the Applicant: Date:

5 Odd Fellow & Rebekah Rehabilitation & HCC, Inc. 104 Old Niagara Road Lockport NY Sworn Statement or Affirmation (Please Print) Last Name First Middle Maiden Social Security # Current Mailing Street, PO Box, Apt # City State Zip Code 1. Have you ever been convicted of or are you the subject of pending charges of any crime or violation other than a traffic infraction? YES YES (Pending) No If yes or pending, specify: 2. Have you ever been the subject of a founded complaint or resident or patient abuse? YES NO If yes or pending, specify: I hereby affirm that the information provided on this form is true and complete. I understand that the information is subject to verification, and any false statements regarding any such offense is guilty of Class 1 Misdemeanor. Signature: Date: Authorization for Search and Exchange of Information I, (name of applicant), hereby authorize Odd Fellow & Rebekah Rehabilitation & HCC, Inc. to submit a request to the Attorney General of the United States to conduct a search of the records of the Criminal Justice Information Services Division of the Federal Bureau of Investigation for any criminal history records corresponding to the fingerprints or other identification information submitted by me. I further authorize the exchange of such information between the Attorney General of the United States, The New York State Department of Health and Odd Fellow & Rebekah Rehabilitation & HCC, Inc. This information may be used only by Odd Fellow & Rebekah Rehabilitation & HCC, Inc. and only for purposes of determining my suitability for employment in a position involved in direct patient care. Signature: Date: Name: (Print please)

6 This page has been left blank intentionally Please go to the last page of this application and sign reference authorizations

7 FOR PERSONNEL DEPARTMENT USE ONLY Arrange Interview: YES / NO Time/Date for Interview: Remarks: Interviewed by: Date of Interview: Verify and Print search results from each website listed: Inspector General Sex Offender Registry CNA Registry If Licensed Staff (RN, LPN, Therapist, Dietician etc.) Employed: YES / NO Date of Hire: Job Title: Rate of Pay: Department: Entered by: Title: Date:

8 This page has been left blank intentionally

9 Odd Fellow & Rebekah Rehabilitation & HCC, Inc. 104 Old Niagara Road, Lockport NY Phone: (716) Fax: (716) Authorization for Release of Information I hereby authorize the release of information concerning my qualifications for employment, to Odd Fellow & Rebekah Rehabilitation & HCC, Inc., 104 Old Niagara Road, Lockport NY Signature: Date: Social Security #: Position Applied: Odd Fellow & Rebekah Rehabilitation & HCC, Inc. 104 Old Niagara Road, Lockport NY Phone: (716) Fax: (716) Authorization for Release of Information I hereby authorize the release of information concerning my qualifications for employment, to Odd Fellow & Rebekah Rehabilitation & HCC, Inc., 104 Old Niagara Road, Lockport NY Signature: Date: Social Security #: Position Applied: Odd Fellow & Rebekah Rehabiliitation & HCC, Inc. 104 Old Niagara Road, Lockport NY Phone: (716) Fax: (716) Authorization for Release of Information I hereby authorize the release of information concerning my qualifications for employment, to Odd Fellow & Rebekah Rehabilitation & HCC, Inc., 104 Old Niagara Road, Lockport NY Signature: Date: Social Security #: Position Applied:

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