Application for Employment





Licensed Personnel



Secretarial/Clerical Personnel

Specialized Skills & Qualifications



Are you at least 18 years of age? YesNo

Are you legally authorized to work in the US?YesNo
Pursuant to the Immigration Reform and Control Act of 1986, all applicants who are offered employment must produce documents establishing their identity and authorization for employment in the United States. These documents must be produced no later than seventy-two (72) hours after employment commences. In addition, all new hires will be required to verify their employment authorization under oath by signing INS Form 1-9.


Have you ever been convicted of a crime other than minor traffic violations? YesNo
[A CONVICTION RECORD WILL NOT NECESSARILY BE A BAR TO EMPLOYMENT.]

IF YES, GIVE DATE, PLACE, AND NATURE OF OFFENSE


Employment Record
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References




ALL OF THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND MAY BE INVESTIGATED BY THE AGENCY. IT IS UNDERSTOOD THAT ANY FALSE STATEMENT BY ME IN THIS APPLICATION WILL BE CAUSE FOR REJECTION OR DISMISSAL AND THAT MY EMPLOYMENT IS CONTINGENT UPON SATISFACTORY REFERENCES, SATISFACTORY COMPLETION OF THE PHYSICAL EXAMINATION AND SATISFACTORY COPMPLETION OF ALL OTHER APPLICABLE REQUIREMENTS.

PURSUANT TO IRCA OF 1986 ALL APPLICANTS, UPON BEING MADE AN OFFER OF EMPLOYMENT MUST PRODUCE DOCUMENTS SPECIFIED BY THE FEDERAL GOVERNMENT, ESTABLISHING THEIR IDENTITY AND AUTHORIZATION FOR EMPLOYMENT IN THE U.S. THESE DOCUMENTS MUST BE PRODUCED NO LATER THAN 72 HOURS AFTER COMMENCEMENT OF EMPLOYMENT. YOU WILL ALSO BE REQUESTED TO SIGN FORM I-9 VERIFYING YOUR EMPLOYMENT AUTHORIZATION.

EFFECTIVE APRIL 1, 2005, ALL NON-LICENSED APPLICANTS WHO PROVIDE DIRECT PATIENT/CLIENT CARE ARE REQUIRED TO BE FINGERPRINTED. THESE FINGERPRINTS ARE SUBMITTED TO THE US ATTORNEY GENERAL AND FBI TO CONDUCT A CRIMINAL HISTORY SEARCH. IF EMPLOYED, ALL EMPLOYMENT IS ON A PROVISIONAL BASIS FOR UP TO 60 CALENDAR DAYS FROM THE DATE THE RECORD CHECK IS REQUESTED. IF THE RECORD CHECK IS NOT COMPLETED , THIS PROVISIONAL PERIOD MAY, AT THE OPERATOR’S OPTION , BE EXTENDED AN ADDITIONAL 60 DAYS OR UNTIL THE RECORD CHECK IS COMPLETED, WHICHEVER IS SOONER. A RECORD CHECK WHICH REVEALS A CONVICTION OF A CLASS A, B, C,D,E FELONY, ENDANGERING THE WELFARE OF A VULNERABLE ELDERLY PERSON OR ANY COMPARABLE OFFENSE WITHIN THE PAST 10 YEARS WILL NOT, IN ACCORDANCE WITH DOH REGULATIONS, CONTINUE TO BE EMPLOYED. ALL OTHER FINAL HIRING DECISIONS WILL BE MADE IN ACCORDANCE WITH OTHER APPLICABLE LAWS AND REGULATIONS.

ONCE EMPLOYED, I UNDERSTAND THAT MY EMPLOYMENT IS FOR NO DEFINITE PERIOD OF TIME, AND IF TERMINATED, THE AGENCY IS LIABLE ONLY FOR WAGES OR SALARY EARNED AS OF THE DATE OF TERMINATION.

FEDERAL AND STATE LAW PROHIBIT DISCRIMINATION DUE TO AGE, RACE, SEX, CREED, COLOR, NATIONAL ORIGIN, MARITAL STATUS, SEXUAL ORIENTATION, CITIZENSHIP STATUS, OR PHYSICAL OR MENTAL DISABILITY WHICH IS UNRELATED TO THE APPLICANT'S ABILITY TO PERFORM THE ESSENTIALS FUNCTIONS OF THE JOB.